Top 10 Most Read AORN Journal Articles

TOP 10
MOST READ
AORN JOURNAL ARTICLES
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As a thank you for renewing, we are excited to provide this unique assortment of the top 10 most read AORN
Journal articles. From guideline implementation to perioperative safe practice, catch up on articles you may
have missed that other AORN members have found quite popular over the last year.
As a member, your monthly AORN Journal provides evidence-based guidelines, peer-reviewed articles, and other
best practices that convey the standard of excellence in perioperative nursing, and helps you stay up-to-date and
improve your own practice every day.
Enjoy.
Top 10 Most Read AORN Journal Articles:

Guideline Implementation: Surgical Instrument Cleaning (May 2015).......................................................... Page 3
Safety Culture and Care: A Program to Prevent Surgical Errors (April 2015)............................................... Page 11
Guideline Implementation: Surgical Attire (Feb. 2015)................................................................................ Page 20
Surgical Team Mapping: Implications for Staff Allocation and Coordination (Feb. 2015)............................. Page 27
Back to Basics: Implementing Evidence-Based Practice (Jan. 2015)......................................................... Page 38
Nursing Shortages in the OR: Solutions for New Models of Education (Jan. 2015)..................................... Page 49
The Role of the OR Environment in Preventing Surgical Site Infections (Dec. 2014)................................... Page 71
Back to Basics: Implementing the Surgical Checklist (Nov. 2014).............................................................. Page 77
Developing Strategies for On-Call Staffing: A Working Guideline for Safe Practices (Oct. 2014).................. Page 86
Hemostatic Agents: A Guide to Safe Practice for Perioperative Nurses (Aug. 2014).................................... Page 93
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CONTINUING EDUCATION
Guideline Implementation:
Surgical Instrument Cleaning
1.3
www.aorn.org/CE
LIZ COWPERTHWAITE, BA; REBECCA L. HOLM, MSN, RN, CNOR

Continuing Education Contact Hours
Accreditation
indicates that continuing education (CE) contact hours are

available for this activity. Earn the CE contact hours by
reading this article, reviewing the purpose/goal and objectives,
and completing the online Examination and Learner Evaluation at http://www.aorn.org/CE. A score of 70% correct on the
examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully
completes this program can immediately print a certicate of
completion.
AORN is accredited as a provider of continuing nursing

education by the American Nurses Credentialing Centers
Commission on Accreditation.
Event: #15517
Session: #0001
Fee: Members $10.40, Nonmembers $20.80
The contact hours for this article expire May 31, 2018. Pricing
is subject to change.
Purpose/Goal
To provide the learner with knowledge specic to implementing the updated AORN Guideline for cleaning and care
of surgical instruments.
Objectives
1. Explain the importance of processing surgical instruments
correctly.
2. Describe steps that should be performed intraoperatively to
prepare instruments for disinfection.
3. Describe the steps in the decontamination process.
4. Identify heating, ventilation, and air conditioning parameters (HVAC) specic to the decontamination area.
5. Identify special precautions to observe during instrument
processing.
Approvals
This program meets criteria for CNOR and CRNFA recertication, as well as other CE requirements.
AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your
state board of nursing for acceptance of this activity for relicensure.
Conict of Interest Disclosures

Ms Cowperthwaite and Ms Holm have no declared afliations
that could be perceived as posing potential conicts of interest
in the publication of this article.
The behavioral objectives for this program were created by
Rebecca Holm, MSN, RN, CNOR, clinical editor, with
consultation from Susan Bakewell, MS, RN-BC, director,
Perioperative Education. Ms Holm and Ms Bakewell have no
declared afliations that could be perceived as posing potential
conicts of interest in the publication of this article.
Sponsorship or Commercial Support

No sponsorship or commercial support was received for this
article.
Disclaimer
AORN recognizes these activities as CE for RNs. This
recognition does not imply that AORN or the American
Nurses Credentialing Center approves or endorses products
mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2015.03.005
AORN, Inc, 2015
542 j AORN Journal
www.aornjournal.org
Surgical Instrument Cleaning
1.3
www.aorn.org/CE
ABSTRACT
Cleaning, decontaminating, and handling instructions for instruments vary widely based on the type of
instrument and the manufacturer. Processing instruments in accordance with the manufacturers instructions can help prevent damage and keep devices in good working order. Most importantly,
proper cleaning and disinfection may prevent transmission of pathogenic organisms from a contaminated device to a patient or health care worker. The updated AORN Guideline for cleaning and care
of surgical instruments provides guidance on cleaning, decontaminating, transporting, inspecting,
and storing instruments. This article focuses on key points of the guideline to help perioperative
personnel implement appropriate instrument care protocols in their practice settings. The key points
address timely cleaning and decontamination of instruments after use; appropriate heating, ventilation, and air conditioning parameters for the decontamination area; processing of ophthalmic instruments and laryngoscopes; and precautions to take with instruments used in cases of suspected
prion disease. Perioperative RNs should review the complete guideline for additional information
and for guidance when writing and updating policies and procedures. AORN J 101 (May 2015) 543-549.
AORN, Inc, 2015. http://dx.doi.org/10.1016/j.aorn.2015.03.005
Key words: cleaning, decontamination, HVAC, ophthalmic instruments, laryngoscopes, prion diseases.
AORN, Inc, 2015
www.aornjournal.org
AORN Journal j 543
CowperthwaitedHolm
nstruments used in surgery should be properly cleaned

and decontaminated and in good working order. Items
that are soiled or working incorrectly could compromise
patient care.1-5 Perioperative personnel should process instruments according to the manufacturers written instructions
for use (IFU). Proper cleaning and disinfection may prevent
transmission of pathogenic organisms from a contaminated
device to a patient or health care worker.1,3,4,6-10
The AORN Guideline for cleaning and care of surgical instruments11 (formerly titled Recommended practices for
cleaning and care of surgical instruments) was updated in
September 2014. AORN guideline documents provide
guidance based on an evaluation of the strength and quality
of the available evidence for a specic subject. The
guidelines apply to inpatient and ambulatory settings and are
adaptable to all areas where operative and other invasive
procedures may be performed.
Topics addressed in the updated instrument cleaning guideline
include care of new, repaired, refurbished, and loaned instruments and devices; requirements for the sterile processing
areas; cleaning products and equipment; instrument inspection; and special precautions to observe during instrument
processing.11 This article elaborates on key takeaways from the
guideline document; however, perioperative RNs should
review the complete guideline for additional information and
for guidance when writing and updating policies and
procedures.
Key takeaways from the AORN Guideline for cleaning and
care of surgical instruments include the following:
Instruments should be cleaned and decontaminated as soon

as possible after use.
The heating, ventilation, and air conditioning (HVAC)
system in the decontamination area should be maintained
within the HVAC design parameters at the rate that was
applicable at the time of design or most recent renovation of
the HVAC system.
Special precautions should be taken when processing intraocular ophthalmic instruments.
Laryngoscope blades and their handles should be cleaned,
decontaminated, dried, and stored in a manner that reduces
patient and personnel risk of exposure to potentially pathogenic microorganisms.
Special precautions should be taken to minimize the risk of
transmission of prion diseases from contaminated instruments (Figure 1).
544 j AORN Journal
May 2015, Volume 101, No. 5
SCENARIO
Nurse M is the scrub person for a cataract procedure. During
the procedure, Nurse M removes gross soil from the instruments by wiping the instruments with a sterile, lint-free
sponge that has been moistened with sterile water. She also
periodically irrigates the lumens of instruments with sterile
water to remove gross soil, immediately after use if possible.
When the procedure is completed, Nurse M segregates the sharp
instruments from the others and puts them into a punctureresistant container. She removes the disposable sharp items
and puts them in a puncture-resistant, leakproof container with
a biohazard label. Nurse M opens the hinged instruments (eg,
tenotomy scissors) and disassembles the irrigation/aspiration
handpiece according to the manufacturers written IFU. She
separates delicate instruments and heavy instruments into
different containers so that the delicate instruments will not be
damaged during transport to the decontamination area. To keep
the instruments moist, she places a towel moistened with sterile
water over the instruments. She sends all of the instruments that
have been opened on the sterile eld to be processed in the
sterile processing area, whether or not they have been used.
Technician G arrives at work, changes into scrub attire, and
reports to the sterile processing area. As his rst task of the day,
he checks and documents the HVAC parameters in this area,
which are maintained at

two outdoor air changes per hour,

six total air changes per hour,
negative air pressure, and
temperature between 72 F and 78 F (22 C and 26 C).
Technician G puts on personal protective equipment so that

his skin will be protected from splashes and splatters from
contaminated instruments and his hands will be protected
from a potential sharps injury. The personal protective
equipment includes a uid-resistant gown with sleeves, general
purpose utility gloves with a cuff that extends beyond the cuff
of the gown, a mask with a full face shield, and shoe covers.
Nurse M brings a closed instrument and supply transport cart
from the cataract procedure to the sterile processing area.
Technician G receives the cart and takes it to a designated
cleaning area away from the area for cleaning general surgical
instruments. He uses cleaning products that are compatible
with the instruments in accordance with the manufacturers
IFU. After cleaning, he rinses the instruments thoroughly with
copious amounts of water and performs a nal rinse with
www.aornjournal.org
Guideline Implementation: Instrument Cleaning
Figure 1. Key takeaways from the AORN Guideline for cleaning and care of surgical instruments.
sterile deionized water. He cleans the lumen of the irrigation/
aspiration handpiece with a brush of the appropriate diameter
and length to clean the entire lumen and exit at the distal end.
The bristles are soft enough to prevent damage to the interior
of the lumen. He rinses the lumen with sterile deionized water
and expels the water into a drain. He then dries the lumen
with medical-grade compressed air.
In accordance with the manufacturers IFU, Technician G
disinfects the instruments by wiping the outside of the instruments with 70% alcohol. He inspects the instruments
under magnication to make sure there is no residual
ophthalmic viscoelastic material present. He records the
cleaning method, cleaning solution, and lot number of the
cleaning solution for the ophthalmic instruments. Technician
G then sends the instrument set to the packaging and sterilization area, where Technician K will wrap and sterilize the set
according to the manufacturers IFU.
www.aornjournal.org
Technician G then receives a laryngoscope handle and blade

from the emergency department. After cleaning and decontaminating the handle and blade according to the manufacturers written IFU, he sends them to the packaging and
sterilization area. Although laryngoscope handles are classied
as noncritical items that only require low-level disinfection,12
at this facility, both the handle and blade are considered
semicritical items, which require high-level disinfection or
sterilization.12 Technician K wraps the blade in an individual
package for storage and sterilizes both the handle and blade
according to the manufacturers written IFU.
Technician G is now processing neurosurgical instruments.
During a preoperative screening, the patient who underwent the
procedure was determined to be at high risk for having a prion
disease (ie, variant Creutzfeldt-Jakob disease). The preoperative
nurse communicated this information to the entire perioperative
team, including the sterile processing personnel, so that they
AORN Journal j 545
CowperthwaitedHolm
could follow the recommended precautions. Many of the instruments used in the procedure were designated for single use
only, so the scrub person discarded them in a contaminated
trash receptacle in the OR. The scrub person sent only reusable
instruments that are easy to clean and can tolerate extendedcycle steam sterilization for sterile processing after the procedure.
Technician G decontaminates the instruments that may have
been exposed to variant Creutzfeldt-Jakob disease in a mechanical washer, which helps ensure cleaning consistency that
may not be achieved with manual cleaning. He uses cleaning
chemicals that have shown evidence of prionicidal activity and
are compatible with the instruments. After decontamination,
Technician G sends the instruments to the packaging and
sterilization area. He then cleans and disinfects the noncritical
environmental surfaces in the decontamination area that came in
contact with the contaminated instruments used on the patients
high-risk tissue. He uses a 1:5 dilution of hypochlorite solution,
ensuring that the solution remains in contact with the environmental surfaces for 15 minutes.13,14 Meanwhile, Technician
K steam sterilizes the instruments in a prevacuum sterilizer at
273 F (134 C) for 18 minutes, which is one of the methods
recommended for use when steam sterilizing instruments that
have been exposed to high-risk tissue.13,15
KEY TAKEAWAYS DISCUSSION

The key takeaways from the AORN Guideline for cleaning
and care of surgical instruments address timely cleaning and
decontamination of instruments after use, appropriate HVAC
parameters for the decontamination area, processing of
ophthalmic instruments and laryngoscopes, and precautions to
take with instruments used in suspected cases of prion disease.
These takeaways do not cover the entire guideline. Rather,
they help the reader focus on important or new information
that should be implemented into perioperative practice.
Immediate Cleaning and Decontamination

Cleaning instruments as soon as possible after use can help to
prevent formation of biolm.11(p619) In the scenario, Nurse
M begins the process of preparing instruments for
decontamination by removing the gross soil at the point of
use.16-18 She understands that dried blood and other organic
material could be corrosive to the instrument
surfaces.16,17,19,20 Allowing blood or other bioburden to dry
on instruments could make it more difcult to remove and
could compromise the effectiveness of the subsequent
disinfection or sterilization.8,16,18,19 Likewise, Nurse M
periodically irrigates the instruments with lumens to remove
gross soil and reduce the risk of biolm formation. A biolm
546 j AORN Journal
that forms in a lumen can be difcult to see and remove.21

She keeps the instruments moist by placing a towel
moistened with sterile water over the instruments. She does
not use saline, which could cause pitting of the
instruments.16,17 She sends all the instruments that have
been opened on the sterile eld to the sterile processing area
for cleaning and decontamination because contamination of
unused instruments can occur without being noticed.17
HVAC Parameters
The HVAC system controls the room air quality, humidity,
temperature, and air pressure. The system is designed to
reduce environmental contaminants as well as to provide a
comfortable environment for those working in the sterile
processing area. In the scenario, the HVAC parameters are set
according to recommendations from the American Society of
Heating, Refrigerating and Air-Conditioning Engineers22 and
the Facility Guidelines Institute.23
The HVAC parameters in the decontamination area should be
those that are applicable at the time of the design of the HVAC
system or the most recent renovation of the system.24 If
personnel detect a variance in the HVAC parameters, they
should report the variance according to the facilitys policy
and procedure. Designated personnel should correct the
variance and then perform a risk assessment to determine
whether any measures need to be taken to restore the
decontamination area to full functionality.24
Ophthalmic Instruments
Inadequate cleaning and rinsing of intraocular ophthalmic
instruments have been implicated in outbreaks of toxic anterior segment syndrome (TASS), an acute inammation of the
anterior segment of the eye, which is most commonly associated with cataract surgery.25 Among other factors, incidents of
TASS have been associated with various facets of instrument
processing,5,26-35 including
detergent residues remaining on instruments,
insufcient rinsing of instruments,
dried debris and residues of ophthalmic viscoelastic material
remaining on instruments, and
insufciently dried lumens.
In the scenario, Technician G cleans the intraocular instruments in an area separate from the general surgery instruments to help prevent cross-contamination from heavily
soiled nonophthalmic instruments.16 He uses cleaning
products recommended by the instrument manufacturers16,36
and rinses the instruments thoroughly to help remove
residual cleaning product.36 When rinsing the lumens,
www.aornjournal.org
Resources for Implementation
Guidelines Implementation: Cleaning and Care of

Instruments and Powered Equipment web page.
AORN, Inc. https://www.aorn.org/Topics_of_Interest/
Sterilization_and_Disinfection/Cleaning_and_Care_of_
Instruments_and_Powered_Equipment/.
AORN Syntegrity Framework. AORN, Inc. http://
www.aorn.org/syntegrity.
ORNurseLinkTM. http://www.ornurselink.org/home.
Perioperative Competency Verication Tools and Job
Descriptions [CD-ROM]. Denver, CO: AORN, Inc;
2014. http://www.aorn.org/CompetencyTools.
Policy and Procedure Templates [CD-ROM]. 4th ed.
Denver, CO: AORN, Inc; 2015. http://www.aorn.org/
Books_and_Publications/AORN_Publications/Policy_and_
Procedure_Templates.aspx.
The Roadmap to ASC Compliance [CD-ROM]. Denver,
CO: AORN, Inc; 2012. https://www.aornbookstore.org//
Product/product.asp?skuMAN543&dept_id1.
Syntegrity is a registered trademark and ORNurseLink is a
trademark of AORN, Inc, Denver, CO.
Web site access veried March 17, 2015.
Technician G expels the uid from the lumen into the drain to
prevent recontamination of the rinse water with debris from
inside the lumen. He uses sterile deionized water to rinse the
instruments because untreated water may contain
endotoxins16,37 or may cause stains, deposits, or corrosion of
the instrument surface.38,39 He dries the lumens with
compressed air29,36 to eliminate moisture that could foster
microbial growth.
Laryngoscope Blades and Handles

As a potential source of contamination, laryngoscope blades
should be cleaned and high-level disinfected or sterilized after
each use according to the manufacturers written IFU. A
laryngoscope blade is considered a semicritical device because it
comes in contact with mucus membranes; therefore, at a
minimum, it should undergo high-level disinfection.12,40 A
laryngoscope handle is classied as a noncritical device and
thus requires only cleaning and low-level disinfection12 unless
the manufacturers IFU specify high-level disinfection or
sterilization. In a comprehensive integrative review of
laryngoscope blades and handles as sources of crossinfection,41 however, the authors recommended that because
they are used concurrently, both the laryngoscope blade and
www.aornjournal.org
What Else Is in the Guideline?
Read the AORN Guideline for cleaning and care of

surgical instruments1 to learn what the evidence says
about the following:
What items should be evaluated to determine whether
a facility has the capability to comply with manufacturers instructions for instrument processing?
(Recommendation I.b.)
What should be included in policies and procedures for
managing loaned instruments? (Recommendation
II.e.)
What accessories and supplies should be stocked in the
decontamination area? (Recommendation V.e.)
When should water quality assessments be conducted?
(Recommendation VII.b.)
What types of detergents should be used for instrument cleaning? (Recommendation VIII.a.1.)
Why should only instruments made of similar metals
be combined in the ultrasonic cleaner? (Recommendation IX.e.4)
1. Guideline for cleaning and care of surgical instruments. In:
Guidelines for Perioperative Practice. Denver, CO: AORN, Inc;
2015:615-650.
handle should be classied as semicritical. The rough surface

of the laryngoscope handle can accumulate bioburden,41,42
which could be transferred to the laryngoscope blade when
the blade is folded closed.41-44
Technician K packages the blade to prevent recontamination.12 Storing the blade in the individual package minimizes
the chance that the blade will become contaminated, which
could happen if a contaminated blade was placed into a
package containing multiple uncontaminated blades.45
Prion Disease Precautions

A prion is a small infectious protein that can cause neurological
diseases known as transmissible spongiform encephalopathies,
such as Creutzfeldt-Jakob disease.13 Instruments that have
contacted high-risk tissue in patients at risk for a prion
disease require adequate decontamination to reduce the risk
for patients who subsequently are treated using these
instruments. Neurosurgical instruments are of particular
concern because typically there are large concentrations of
prions in the brain and spinal cord.46 Prions are known to
be resistant to conventional physical and chemical
sterilization techniques.13 Because the preoperative nurse
AORN Journal j 547
CowperthwaitedHolm
notied sterile processing personnel in advance of the patients

prion status, Technicians G and K were prepared to
implement special precautions and protocols, which are
required to inactivate prions. Technician G processes the
instruments according to the 2010 Society for Healthcare
Epidemiology of America Guideline for disinfection and
sterilization of prion-contaminated medical instruments13
and the facilitys policies.
CONCLUSION
As the patients advocates, perioperative nurses help ensure
that actions are performed to promote patient safety. This
includes making sure instruments are in good working order
and have been correctly processed according to the manufacturers written IFU to reduce the chance of transmitting
pathogenic microorganisms to patients or personnel. Perioperative RNs and sterile processing team members who have
responsibilities related to care and cleaning of surgical instruments should receive education and complete competency
verication on instrument care and cleaning activities. In
addition, perioperative RNs should participate in multidisciplinary teams that include infection preventionists, surgeons,
sterile processing personnel, and other stakeholders to
develop mechanisms for evaluating and selecting cleaning
and decontamination equipment and associated cleaning
products,
implement systematic processes for monitoring HVAC parameters in the sterile processing areas and addressing variances in those parameters, and
establish evidence-based policies and procedures to minimize
the risk of prion disease transmission.
The AORN Guideline for cleaning and care of surgical instruments is an evidence-based resource that perioperative
RNs and sterile processing team members can use to help
inuence safe perioperative practice.
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39. Proper Maintenance of Instruments. 8th ed. Morfelden-Walldorf,
Germany: Arbeitskreis Instrumenten-Aufbereitung [Instrument
Working Group]; 2004.
40. Tablan OC, Anderson LJ, Besser R, et al. Guidelines for preventing
health-careeassociated pneumonia, 2003: recommendations of
CDC and the Healthcare Infection Control Practices Advisory
Committee. MMWR Recomm Rep. 2004;53(RR-3):1-36.
41. Negri de Sousa AC, Levy CE, Freitas MI. Laryngoscope blades and
handles as sources of cross-infection: an integrative review.
J Hosp Infect. 2013;83(4):269-275.
42. Williams D, Dingley J, Jones C, Berry N. Contamination of laryngoscope handles. J Hosp Infect. 2010;74(2):123-128.
43. Call TR, Auerbach FJ, Riddell SW, et al. Nosocomial contamination
of laryngoscope handles: challenging current guidelines. Anesth
Analg. 2009;109(2):479-483.
44. Howell V, Thoppil A, Young H, Sharma S, Blunt M, Young P.
Chlorhexidine to maintain cleanliness of laryngoscope handles: an
audit and laboratory study. Eur J Anaesthesiol. 2013;30(5):
216-221.
45. Standards FAQs details: laryngoscopesdblades and handlesd
how to clean, disinfect and store these devices. The Joint Commission. http://www.jointcommission.org/mobile/standards_inform
ation/jcfaqdetails.aspx?StandardsFAQId508&StandardsFAQChapter
Id69. Accessed February 4, 2015.
46. McDonnell G. Prion disease transmission: can we apply standard
precautions to prevent or reduce risks? J Perioper Pract. 2008;
18(7):98-304.
Liz Cowperthwaite, BA
is the senior managing editor at AORN, Inc, Denver, CO.
Ms Cowperthwaite has no declared afliation that could
be perceived as posing a potential conict of interest in
the publication of this article.
Rebecca L. Holm, MSN, RN, CNOR

is the clinical editor for AORN Journal, AORN, Inc, Denver,
CO, and an RN in perioperative services at Skyridge
Surgery Center, Lone Tree, CO. Ms Holm has no declared
afliation that could be perceived as posing a potential
conict of interest in the publication of this article.
AORN Journal j 549
Safety Culture and Care:

A Program to Prevent
Surgical Errors 1.8
www.aorn.org/CE
MAUREEN WHITE HEMINGWAY, MHA, RN; CATHERINE OMALLEY, MSN, RN;

SANDRA SILVESTRI, MS, RN, CNOR
Approvals

available for this activity. Earn the CE contact hours by reading
this article, reviewing the purpose/goal and objectives, and
completing the online Examination and Learner Evaluation at
http://www.aorn.org/CE. A score of 70% correct on the examination is required for credit. Participants receive feedback on
incorrect answers. Each applicant who successfully completes
this program can immediately print a certicate of completion.
Event: #15513
Session: #0001
The contact hours for this article expire April 30, 2018.
Pricing is subject to change.
Purpose/Goal
To provide the learner with knowledge specic to developing a
perioperative quality and safety program to prevent surgical errors.
AORN is provider-approved by the California Board of

Registered Nursing, Provider Number CEP 13019. Check
with your state board of nursing for acceptance of this activity
for relicensure.

Maureen White Hemingway, MHA, RN; Catherine OMalley,
MSN, RN; and Sandra Silvestri, MS, RN, CNOR, have no
Helen Starbuck Pashley, MA, BSN, CNOR, clinical editor,
with consultation from Susan Bakewell, MS, RN-BC, director,
Perioperative Education. Ms Starbuck Pashley and Ms Bakewell have no declared afliations that could be perceived as
posing potential conicts of interest in the publication of this
article.
Objectives
1. Describe how a culture of safety affects patient care.
2. Identify how perioperative personnel can prevent adverse
events and errors.
3. Discuss how to enhance a quality and safety program.

article.
Disclaimer
Accreditation
AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Centers

AORN, Inc, 2015
404 j AORN Journal
www.aornjournal.org
Safety Culture and Care:

A Program to Prevent
Surgical Errors 1.8
www.aorn.org/CE
MAUREEN WHITE HEMINGWAY, MHA, RN; CATHERINE OMALLEY, MSN, RN;

SANDRA SILVESTRI, MS, RN, CNOR
ABSTRACT
Surgical errors are under scrutiny in health care as part of ensuring a culture of safety in which patients
receive quality care. Hospitals use safety measures to compare their performance against industry
benchmarks. To understand patient safety issues, health care providers must have processes in place
to analyze and evaluate the quality of the care they provide. At one facility, efforts made to improve its
quality and safety led to the development of a robust safety program with resources devoted to
enhancing the culture of safety in the Perioperative Services department. Improvement initiatives
included changing processes for safety reporting and performance improvement plans, adding resources and nurse roles, and creating communication strategies around adverse safety events and how
to improve care. One key outcome included a 54% increase in the percentage of personnel who
indicated in a survey that they would speak up if they saw something negatively affecting patient care.
AORN J 101 (April 2015) 405-412. AORN, Inc, 2015. http://dx.doi.org/10.1016/j.aorn.2015.01.002
Key words: safety culture, quality assurance, safety program, preventing surgical errors, process
improvement.
AORN, Inc, 2015
www.aornjournal.org
AORN Journal j 405
Hemingway et al
n 1999, the Institute of Medicine (IOM) published To

Err Is Human: Building a Safer Health Care System,1 an
eye-opening report that focused on reducing the rate of
preventable medical errors and the serious consequences of
these errors to patients. Data from the IOM report indicated
that an estimated 100,000 patients died each year as a result
of preventable medical errors.1 As a result of the IOM
report, the majority of health care facilities established
patient safety changes. However, according to a 2013
systematic review of several articles, the true number of
premature deaths associated with preventable harm to
patients is estimated at more than 400,000 per year,2(p122)
which shows a remarkable increase in the number of
reported adverse events related to medical errors and patient
harm in the past 15 years.
Commitment to a culture of safety in the perioperative setting
is essential to a hospitals ability to improve patient care,
prevent surgical errors, and function as a high-reliability organization. Improving delivery of care requires analyzing performance measures to identify safety or quality issues.
Reporting measures allow facilities to collect data necessary to
evaluate the relevancy and frequency of safety or quality issues.
In addition, databases populated with real-time information
allow individual practitioners and members of a department, a
hospital, or even an entire health care system to measure,
benchmark, and design measurable quality improvement (QI)
programs. Having high-quality safety culture data at a unit
level allows the team to identify specic areas of weakness or
cultural opportunity for improvement.3(p289) Subsequent to
analysis of reporting measures and identication of a safety
or quality issue, personnel can develop and implement
process improvement plans.
In 2006, personnel at Massachusetts General Hospital
(MGH), Boston, undertook initiatives to improve the hospitals quality and safety program. This article describes the
process changes that led to enhanced quality assurance (QA) in
MGHs Perioperative Services department.
HISTORICAL APPROACHES TO QUALITY

AND SAFETY
Massachusetts General Hospital is a level I trauma teaching
hospital in Boston, where personnel care for approximately
36,000 surgical patients each year. At MGH, a steady growth
in the number of surgical procedures has corresponded with an
increase in the hospitals surgical capacity, which has resulted
in the need for a more robust quality and safety program.
406 j AORN Journal
April 2015, Volume 101, No. 4
Historically, within the structure of MGHs safety program,

personnel involved in any untoward or unexpected clinical
happening in the perioperative setting were expected to write
an incident report. Some personnel expressed concern about a
reporting process that could be misused in the form of retribution against the individuals involved in the incident. At that
time, to address staff perception of this process, hospital leaders
changed the required incident report to a safety report. By
writing a safety report, personnel could acknowledge the event
without fear of punitive or disciplinary actions from facility
managers or administrators. Despite this change, additional
concerns about MGHs safety program remained. Personnel
voiced concerns related to two aspects of the former safety
reporting system
a lack of feedback from managers to staff members after
submission of a safety report, and
the absence of performance improvement plans to address
opportunities for employee growth.
The perception shared by personnel was that safety reports
were simply relegated to a le cabinet without discussion of
how to address safety and quality issues. The difculty shared
by managers was the lack of necessary data relevant to system
issues, such as perioperative patient positioning injuries, to
develop a performance improvement program.
PERFORMANCE IMPROVEMENT PLANS

The demands of a busy surgical day previously would hamper
managers efforts toward implementing safety and process
improvement programs. In general, the health care eld can be
lled with people who want to provide optimal clinical care.
Although it would be unfair to say that there was a culture of
low expectations at MGH, this may have been the perception
shared by personnel. As a result of the IOMs 1999 report,
leaders at MGH recognized that health care practitioners and
facility personnel must identify preventable adverse events and
create an environment dedicated to transparency. To that end,
MGH perioperative services personnel have continually sought
to put systems into place to address perioperative errors,
including the process improvements discussed in this article.
Subsequent reporting and evaluation of preventable medical
errors2 have reinforced the importance of our project to
patient safety.
DEVELOPING A PROGRAM FOR

IMPROVED SAFETY AND CARE
Improvements to the safety culture at MGH began in 2006,
after hospital leaders and personnel determined that a just
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culture, in which individuals feel comfortable in reporting near

misses or errors, was the right environment to nurture. This
initiative represented a multidimensional effort by the institutions leadership team, with assessment and development
of specic categories to enhance the safety culture. First
institutionally related steps included meeting the following
objectives:
development of an enhanced and more responsive electronic
safety reporting system,
implementation of a system of safety behavior auditing and
feedback,
creation of ongoing facility-wide dissemination of safety issues and relevant modication of policies and procedures,
addition of developmental steps within the Perioperative
Services department,
promotion of consistent policy for debrieng of safety reports with all involved personnel, and
addition of new nursing positions specically focused on
safety and quality within perioperative services.
PROCESS CHANGES
During the change process, administrators and members of the
project team fully supported and included perioperative
nursing leaders, including the associate chief nurse, nursing
director, and nurse consultants. Following are changes instituted during this process improvement.
Safety Reporting Measures

Members of the project team made revisions to the electronic
safety reporting system that assists caregivers with providing
quality care. The scope of these revisions had three
components
capture relevant data (eg, patient intraoperative positioning
injuries),
create databases to identify trends (eg, counting discrepancies), and
track issues (eg, system problems) over time.
One advantage of an electronic safety reporting system is that it
captures trends for particular issues. For example, perioperative
nurses had been concerned about patient positioning injuries,
and by using the hospitals internal web-based safety reporting
system, team members were able to gather information around
this specic issue for evaluation and analysis.
Safety Debriengs
After an adverse safety or quality event occurs, all involved
personnel must conduct an initial safety debrieng session. A
growing body of literature suggests that surgical briengs and
debriengs can result in impressive reductions in morbidity
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Preventing Surgical Errors
and mortality . . . but the evidence to date supports

case-by-case structured brieng and debrieng.4(p1147)
Implementation of safety incident debrieng sessions at
MGH have provided a constructive forum to elicit
information and emphasize a team perspective to quality
patient care. These sessions also inform the use of an
algorithm of discussion points based on the safety report and
individual interviews with participants in the event, with
which managers make determinations on policy and then
strong education or reeducation for personnel.
Audits
Integrated into this quality initiative was the requirement for the
perioperative nurses and leadership team to perform audits.
Audits are a valuable tool to use in monitoring and improving
quality care. Performing audits creates an opportunity for the
perioperative nursing leaders to observe staff member compliance with policies and procedures and provides a way to
investigate hurdles to compliance that personnel may encounter
in their daily nursing practice. For example, an incident
involving a retained foreign body resulted in changes to the
count policy. After initial audits revealed that this change did
not address the root cause in patient care, the policy was revised
again to ensure positive outcomes in patient care.
Although audits may be difcult and time consuming to
conduct, personnel at MGH believe they are a vital link to
compliance and provide an opportunity to explain issues so
that members of the leadership team can discover obstacles to
policy adherence. Personnel should not use workarounds such
as gathering medications for the entire day as opposed to
patient-specic medications. If they are using workarounds,
managers should ask for an explanation about why they are
needed. Another difculty with audits is to assure personnel
that the audit is a nonpunitive action that offers a chance to
improve care, educate staff members, and provide an understanding of current practices.
Communication Methods
Communicating changes in policy or practice is as important as
the changes themselves. In the perioperative setting of a major
trauma center, communication with each individual is a challenge. For the most part, people want to follow the rules. If the
rules change, communication about the change and why it is
necessary is paramount for compliance. One avenue that we have
had great success with is the use of a weekly practice alert
(Figure 1). As part of the improvement initiative, the
perioperative nurse consultants developed an informational
report to reach all clinical staff nurses with timely policy
AORN Journal j 407
Hemingway et al
Figure 1. Example of a weekly practice alert highlighting topics important to nurses.
changes or reminders. The original intent was to send an alert

by e-mail, posting on boards and on MGH ORTV, which is
a digital interactive display system designed to improve
communication across the perioperative services, when a
serious issue had arisen and to remind personnel of an existing
policy or alert them to a change in policy. This has evolved
into a weekly practice alert highlighting important topics that
have occurred over the past week. To create the alert, a weekly
report pulls the most pertinent issues from the safety reports
created over the course of a week, which are formatted as short
one-page summaries of nursing practice issues that every
perioperative staff member receives via e-mail each Friday. The
practice alerts are a popular item with all perioperative nursing
staff. Although the perioperative nurse consultants create the
alerts, quite frequently the staff RNs will send an item that
408 j AORN Journal
they feel should be highlighted in the alert to the perioperative

nurse consultants.
Resources: New Nurse Role

Perioperative services personnel at MGH identied the resources needed to affect positive patient outcomes. As a result,
leaders created new stafng and resource roles within perioperative services to provide support for becoming a highreliability organization. The perioperative environment is a
complex one, with team members of varying education levels.
Nurses are the front-line personnel who care for patients on a
daily basis. Yang et al reported that perioperative nurses play
an important role in ensuring patient safety and reinforce the
necessity of vigilance in the OR.5(p755) The perioperative
administrators and nursing leaders instituted the role of
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perioperative QA staff specialist in the MGH OR and lled the

position with a masters-level senior perioperative nurse capable
of understanding the history and culture of the MGH OR. The
unique aspect of this role is the pairing of a patient safety
perspective with an understanding of providing quality care,
which provides a seamless framework and mind-set for the
QA staff specialist when undertaking relevant and quality
tracer audits related to specic safety reports, as well as when
articulating and processing information to develop a process
improvement plan that addresses specic safety concerns.
The QA staff specialist is present at every staff meeting and is a
role that has come to represent the quality and safety
commitment in perioperative services. This experienced nurse
is able to develop pertinent safety initiatives based on actual
situations and has the ability to start and maintain a dialogue
of concerns and specic safety issues with staff perioperative
nurses who see quality and safety opportunities on a daily
basis. The obvious advantage to this role is that as a perioperative nurse, the QA staff specialist understands the role of the
perioperative nurse.
will take in response to the report. When determining what

feedback will be valuable, the quality and safety team has
found that safety report writers appreciate a follow-up disposition of the issue. The sharing of pertinent and timely information to the front-line staff is important for them to see
the direction of the changes to improve practice.
When there is an event that necessitates an immediate change
in policy, the perioperative nurse consultant team includes the
issue in a practice alert as soon as possible. However, this team
does not solely rely on electronic communication. Important
changes are also discussed in a timely fashion at various staff
meetings. Once a week, the perioperative QA staff specialist
attends the team leader meeting to discuss safety reporting and
any new issues. Finally, there is a dedicated quality and safety
staff meeting held monthly to update the team on the resolution of nonurgent safety reports. Broader changes and trends
are categorized for the staff at this meeting. For instance, the
discussion may revolve around the number of safety reports
related to an environment-of-care issue. The QA staff specialist
may formulate a plan to educate the OR assistants team to use
a standard and consistent approach to environment-of-care
issues. The staff nurses become more involved in these processes because they are encouraged to lead the discussion in
this venue. Keeping the focus on patient care and good nursing
practice allows everyone to be engaged in quality patient care.
When a safety event occurs, another advantage of the QA staff

specialist role is that the management team is separate from
both the safety event and the fact-nding team. The perioperative QA nurse will begin an inquiry into the event to understand the intentions of the person who wrote the safety
report. This is an initial nonthreatening conversation among
staff members to understand the involved factors. If the issue is
a serious reportable event, the perioperative leadership team is
then included in the investigation. The objectivity of the QA
staff specialist is important to building trust and functioning as
a neutral third party. The perioperative nurse consultants and/
or the perioperative QA staff specialist and the involved staff
members conduct initial meetings after a staff member les a
safety report. A nonthreatening conversation ensues during
which the goal is to help understand what happened, not to
assign blame. Thus, this approach fullls the commitment to
maintaining the values of a high-reliability organization, such
as deference to expertise,6(p304) and to ensuring that
collaboration occurs in the perioperative services department
and among the corresponding roles in the departments of
surgery and anesthesia.
From the staff members perspective, what happened?

What would improve future care for the patient and for team
members?
What could the staff member have done differently to
improve the outcome?
What can the staff member commit to changing or doing
differently in the future?7
Communication and Feedback
These questions have helped health care providers engage in

self-reective practices.
In response to long-term staff member complaints that safety

reporting did not provide feedback, the quality and safety team
began sending an e-mail to the reports originator to express
thanks for his or her commitment to improving patient care, as
well as a short note on what actions the quality and safety team
Discovering the root cause of an event also provides an opportunity to review pertinent policy. Sometimes in the course
of these events, it becomes necessary to introduce a policy
change. At times, we have discovered that a policy is open to
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For a serious issue, members of the quality and safety ofce

will task the QA staff specialist to separately interview participants involved in the issue. This gives the participants a
chance to relay their information in a safe environment in
advance of a debrieng meeting, during which the QA staff
specialist will ask the individuals involved to come prepared to
address the following questions developed by the MGH
Quality and Safety Department:
AORN Journal j 409
Hemingway et al
interpretation. No policy should be so restrictive as to inhibit

practice in different situations; however, if the policy is so
vague that personnel struggle to interpret it, then changes must
be made. When reviewing a policy pertinent to an event, the
two questions to ask are
Did the staff members involved follow policy?
Will changing the policy prevent the root cause to this event?
around near misses and adverse events that occurred

within the perioperative environment and to ensure that
changes are being made that enhance and address quality
and safety issues. This is also a forum to discussion of
other safety measures, such as the Universal Protocol.TM
. . . commitment to safety that permeates all levels of an

organization . . . it calls up a number of features identied in
studies of high reliability organizations such as acknowledgement
of the high risk, error-prone nature of an organizations
activities, a blame free environment where individuals are able
to report . . . an expectation of collaboration across ranks to seek
solutions . . . and a willingness on the part of the organization to
direct resources to address safety concerns.8(p443)
Quality assurance differs from QI in that QA is meant to

prevent adverse events by developing processes to address
issues before they become events. In QI, personnel must
identify the issue that resulted in an event and develop an
action plan to address the issue before more harm can
occur.10 At MGH, the PQAC is composed of key
stakeholders within the QA arena and members of the
leadership team, including the executive medical director,
the associate chief of nursing, the directors of perioperative
nursing and the central sterile processing departments, and
surgical and anesthesia representatives. The makeup of the
PQAC helps ensure a comprehensive discussion and
recognition of perioperative safety issues. Furthermore, this
multidisciplinary committee provides a forum for surgical
liaisons to the hospitals quality and safety unit when trying
to reach consensus on patient care issues and report them
to the hospitals QA committee. The strength of this type
of committee comes from the different team members
perspectives and individual strengths. The idea that these
roles are embedded within their respective departments
assists in early identication and continued progress of
patient care improvement and process improvement
projects across departments.
When seeking to improve quality and safety, hospital

leaders and personnel must be able to distinguish between
adverse events and near misses, as well as QA and QI. There
are clear distinctions between an error, an adverse event,
and a near miss. A medical error is dened as an error that
happens in a medical setting and is made by someone who
is engaged in a medical activity.9(p170) An adverse event is
an unexpected problem arising from a health care
encounter, which may be a procedure-, drug-, or systemrelated event. According to Wachter,8 a near miss, or a
close call, is a situation that only by chance did not
produce a patient injury and does not become an adverse
event, whereas an adverse event is any injury directly
caused by medical care. A near miss has the potential to
become an adverse event unless actions are taken to
mitigate the risk. As part of this initiative, a
multidisciplinary team formed and scheduled monthly
meetings to understand and to review the system issues
The team-based commitment to quality and safety has carried

through into other forums. The Perioperative Nurse Consultant team reviews safety reports weekly with the perioperative
QA staff specialist. This team, together with the QA specialist,
has effected change in surgical patient outcomes. For instance,
when cardiac surgical patients were developing pressure ulcers
in the postoperative period, the OR QA personnel began
gathering patient positioning data in response to a call from
the patient care units. The perioperative nurse consultants
were able to trace the genesis of these ulcers back to the length
of the surgical procedure and the required positioning of the
patient in the OR. In response to the perioperative positioning
that resulted in sacral pressure ulcers, the nursing staff began to
use Mepilex dressings on cardiac patients to decrease sacral
skin breakdown. Additionally, the nursing staff researched and
recommended the use of uid-infusion mattresses in all cardiac
patients at high risk of perioperative injuries (eg, provide examples of these patients). Both of these interventions have
decreased the prevalence of postoperative pressure ulcers in
cardiac patients to zero.
Policies should reect best practices, and staff members

practices should reect the policy. If the investigation and
debrieng reveal that a policy has become too broad, changes
should be made. All changes to policy at MGH are vetted by
members of the Nursing Practice Committee, Perioperative
Quality Assurance Committee (PQAC), and the Surgical Executive Committee, after which the Perioperative Nurse
Consultants will develop an education plan.
ENHANCING QUALITY AND SAFETY

According to Wachter, the term safety culture may be
dened as
410 j AORN Journal
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Further Understanding of Adverse Events

One aspect of working with a perioperative QA staff specialist
is the education this individual provides to help staff members
understand patient safety issues and embrace commitment to
quality care. Recently, the QA staff specialists focus has been
on helping personnel understand the concepts of adverse
events, risky behavior, and drifting from safe practice.
Adverse events and errors

These can be classied as preventable or unpreventable. Preventable errors can be predicted and remediated, for example,
errors involving technology (ie, equipment malfunctions prevented or remedied by routine inspections). There are situations
in which errors occur that are not preventable (eg, an occurrence
outside the providers control). Unpreventable errors cannot be
predicted or assumed. For example, a debilitated patient may
develop a pressure ulcer after an eight-hour, prone, orthopedictype surgical procedure occurs, even though caregivers worked
appropriately and in the patients best interest. In this instance,
the caregivers are not responsible for the adverse event, but
should take the opportunity to share the experience with other
caregivers to educate them about how to prevent similar adverse
events from occurring again. The focus at MGH has always
been on reducing preventable human errors.
Risky behavior
There is a difference between risky behavior and errors that
result from systems issues, which relates to the concept of
practice drift. According to Reason, Marx (a leading patient
safety expert) has written extensively on human factors as
related to patient care and is credited with the phrase to drift
is human.9 Practice drift occurs when personnel begin to use
small deviations from an accepted practice. Behavioral choices
like practice drift can create risk because they do not follow
accepted best practices. After the deviation becomes familiar,
then it becomes the normal way of performing a task.
Eventually, the small deviation evolves until there is a huge
gap between the health care providers practice and written
policy. It is imperative that staff nurses understand the
concept of practice drift and be ready to counteract it in
themselves and others by regularly reviewing policy and
procedures to help ensure compliance with accepted practice.
To determine whether an error may be preventable, the rst
question that a quality and safety investigation should determine is whether one or more persons are engaging in the
identied behavior. If three or more practitioners report that
they perform the identied behavior on a consistent basis,
there is a systems issue involved. In that case, the organizations
leaders share in the accountability for the problem. Systems
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issues need to be addressed and rectied within a multidisciplinary milieu such as the PQAC and the Practice
Committees.
However, reckless behavior is a conscious choice to engage in a
substantial and unjustiable risk. Leonard and Frankel dene a
risky action as when the caregiver makes a potentially unsafe
choice. A caregiver engaging in a risky action should receive
coaching and participate in educating others in order to apply
lessons learned.3(p290) Reckless behavior may be unintentional
because of impaired judgment or, in some instances, it may be
malicious action in which the individual wanted to cause
harm. Such reckless behavior requires a different response.
Individuals engaged in intentionally harmful behavior must
be managed within the legal system, a substance abuse
program, or an employee assistance program, whichever is
the appropriate venue.
Ongoing Improvement Interventions

Perioperative administrators and nursing leaders are planning
additional interventions to further improve our culture of
safety, but current efforts include
the use of multidisciplinary simulation experiences to
improve team training,
executive and leader walkarounds to engage with front-line
staff members,
the use of surveys that pertain to the culture of safety to
understand the current environment, and
focus groups to identify safety issues.
RESULTS
Implementation of process changes to enhance MGHs safety
program, as well as the addition of the perioperative QA staff
specialist to the OR environment, has contributed to quantiable outcomes. For example, in 2013, perioperative nursing
members conducted a staff survey to understand their OR
culture of safety. Eighty percent of respondents (ie, RNs,
surgical technologists, OR assistants, operational associates)
(n 79) answered negatively to the question, I feel free to
question the decision or actions of those with more authority,
and 44% stated that they would not speak up if they saw
something negatively affecting patient safety. Another survey
question asked which actions would help the respondent to
speak up, and narrative responses included knowing that I
would have support of management and peers and engaging
in a conversation with all parties involved in an incident.
Changes that have been made in the quality and safety arena at
MGH are positively affecting our culture of safety, as evidenced by a follow-up survey conducted in early 2014. Results
of this survey revealed that 72% of respondents (n 90)
AORN Journal j 411
Hemingway et al
would feel free to question the decision or action of those with

more authority, and that 97.7% would speak up if they saw
something negatively affecting patient care.
CONCLUSION
Considering recent estimates of 400,000 patient injuries
related to preventable medical errors occurring in the United
States each year,2 it is imperative to continue QI and safety
improvement efforts. Despite the resources and efforts that
many facilities have allocated to this initiative, there is still
work to be done. According to Kathleen Sibelius, former US
Secretary of Health and Human Services, the Affordable
Care Act has created an opportunity for the health care
industry to begin to coordinate patient care and pay for
quality rather than quantity.11 The role of quality and safety
measures in the care of the patient should continue to
expand, and perioperative nursing goals should include
preventing surgical near misses and adverse events.
Members of a health care organization who believe in everyday
excellence demonstrate specic qualities, such as understanding the complexities of the health care environment and the
belief that collaboration in the institution is key to understanding the importance of reporting adverse events and near
misses. The continued focus at MGH remains on process
improvement projects and a commitment to a safety culture,
which requires many resources at many levels. At MGH our
motto is excellence every day, which means we strive to
perform at our best every day for every patient.
Acknowledgment: The authors wish to acknowledge Patrice

Osgood, RN, MSN, CNOR, NE-BC, nursing director of perioperative services at Massachusetts General Hospital, Boston,
for her review and suggestions during the preparation of this
manuscript.
Editors notes: The Universal Protocol for Preventing Wrong
Site, Wrong Procedure, Wrong Person Surgery is a trademark of
The Joint Commission, Oakbrook Terrace, IL. Mepilex is a
registered trademark of Molnlycke Health Care, Gothenburg,
Sweden.
References
1. Kohn L, Corrigan J, Donaldson M, eds. To Err Is Human: Building a
Safer Health System. Washington, DC: National Academy Press;
2000.
2. James JT. A new evidence-based estimate of patient harms
associated with hospital care. J Patient Saf. 2013;9(3):122-128.
412 j AORN Journal
3. Leonard MW, Frankel A. The path to safe and reliable healthcare.

Patient Educ Couns. 2010;80(3):288-292.
4. Wahr JA, Prager RL, Abernathy JH, et al. Patient safety in the
cardiac operating room: human factors and teamwork, a scientic
statement from the American Heart Association. Circulation. 2013;
128(10):1139-1169.
5. Yang YT, Henry L, Dellinger M, Yonish K, Emerson B, Seifert PC.
The circulating nurses role in error recovery in the cardiovascular
OR. AORN J. 2010;95(6):755-762.
6. Wilson KA, Burke CS, Salas E. Promoting health care safety
through training high reliability teams. BMJ Qual Saf. 2005;14:
303-309.
7. Holden L, Rossi L. Disruptive behavior: what happens next? A
model for assessment and intervention. Presented at: Come
Together: A Gathering of Leading Ideas in Quality and Safety. The
Joint Commission Annual Conference on Quality and Safety; June
9, 2011; Chicago, IL.
8. Wachter RM. Understanding Patient Safety. 2nd ed. New York, NY:
McGraw Hill; 2012. http://langetextbooks.com/0071765786/
downloads/0071765786_Wachter.pdf. Accessed November 20,
2014.
9. Senders JW. Medical devices, medical errors, and medical accidents. In: Reason JT, ed. Human Error in Medicine. New York, NY:
Cambridge University Press; 1994:159-177.
10. Olson BL. Just what does culture have to do with patient safety?
Medscape Multispecialty. http://www.medscape.com/viewarticle/
714617. Accessed December 1, 2014.
11. Sebelius K. Good news on healthcare spending. March 7, 2013.
HHS.gov/HealthCare: US Department of Health and Human Services. http://www.hhs.gov/healthcare/facts/blog/2013/03/health
-care-spending.html. Accessed December 1, 2014.
Maureen White Hemingway, MHA, RN

is a nursing practice specialist at Massachusetts
General Hospital, Boston. Ms Hemingway has no
declared afliation that could be perceived as posing
a potential conict of interest in the publication of this
article.
Catherine OMalley, MSN, RN

is a perioperative quality assurance staff specialist at
Massachusetts General Hospital, Boston. Ms OMalley
has no declared afliation that could be perceived as
posing a potential conict of interest in the publication of
this article.
Sandra Silvestri, MS, RN, CNOR

is a nursing practice specialist at Massachusetts General
Hospital, Boston. Ms Silvestri has no declared afliation
that could be perceived as posing a potential conict of
interest in the publication of this article.
www.aornjournal.org
Surgical Attire 1.0
www.aorn.org/CE

Accreditation

completes this program can immediately print a certicate of
completion.

Event: #15505
Session: #0001
Fee: Members $8, Nonmembers $16
The contact hours for this article expire February 28, 2018.
Purpose/Goal
To provide the learner with knowledge specic to implementing the AORN Guideline for surgical attire.
Objectives
1. Identify the key takeaways from the surgical attire guideline.
2. Explain the steps involved in correctly wearing surgical
attire.
3. Describe methods of correctly handling personal communication or hand-held electronic devices in the OR.
4. Explain why scrub attire should be laundered in a health
careeaccredited laundry facility.
5. Discuss the RNs role in developing policies and procedures
for surgical attire.
Approvals
Registered Nursing, Provider Number CEP 13019. Check
with your state board of nursing for acceptance of this activity
for relicensure.

Ms Cowperthwaite and Ms Holm have no declared afliations
that could be perceived as posing potential conicts of interest
in the publication of this article.
Rebecca Holm, MSN, RN, CNOR, clinical editor, with
consultation from Susan Bakewell, MS, RN-BC, director,
Perioperative Education. Ms Holm and Ms Bakewell have no

article.
Disclaimer
AORN, Inc, 2015
188 j AORN Journal
www.aornjournal.org
Surgical Attire 1.0
www.aorn.org/CE
ABSTRACT
Surgical attire helps protect patients from microorganisms that may be shed from the hair and skin of
perioperative personnel. The updated AORN Guideline for surgical attire provides guidance on
scrub attire, shoes, head coverings, and masks worn in the semirestricted and restricted areas of the
perioperative setting, as well as how to handle personal items (eg, jewelry, backpacks, cell phones) that
may be taken into the perioperative suite. This article focuses on key points of the guideline to help
perioperative personnel adhere to facility policies and regulatory requirements for attire. The key
points address the potential benets of wearing scrub attire made of antimicrobial fabric, covering the
arms when in the restricted area of the surgical suite, removing or conning jewelry when wearing
scrub attire, disinfecting personal items that will be taken into the perioperative suite, and sending
reusable attire to a health careeaccredited laundry facility after use. Perioperative RNs should review
the complete guideline for additional information and for guidance when writing and updating
policies and procedures. AORN J 101 (February 2015) 189-194. AORN, Inc, 2015. http://dx.doi.org/
10.1016/j.aorn.2014.12.003
Key words: surgical attire, scrub clothing, shoes, jewelry, head coverings, masks, cell phones, health
careeaccredited laundry facility.
AORN, Inc, 2015
www.aornjournal.org
AORN Journal j 189
CowperthwaitedHolm
acteria shed from the human body can be a source of

microbial contamination and transmission in the
perioperative setting.1 Wearing surgical attire promotes
cleanliness and hygiene by containing microorganisms that are
shed from the skin and hair of perioperative personnel. Reducing
the surgical patients exposure to microorganisms may help
prevent the patient from developing a surgical site infection
(SSI). Perioperative RNs, working with other perioperative team
members, play a key role in protecting patients by adhering to
and promoting compliance with policies and procedures for
surgical attire.
The AORN Guideline for surgical attire2 (formerly titled

Recommended practices for surgical attire) was updated in
September 2014. AORN guideline documents provide
guidance based on an evaluation of the strength and quality
of the available evidence for a specic subject. The
guidelines apply to inpatient and ambulatory settings and are
adaptable to all areas in which operative and other invasive
procedures may be performed.
Topics addressed in the updated surgical attire guideline
include scrub attire, shoes, head coverings, and masks; jewelry;
and personal items, such as cell phones, tablets, backpacks, and
briefcases. The guideline also addresses the importance of
sending surgical attire to a health careeaccredited laundry facility for laundering. This article elaborates on key takeaways
from the guideline document; however, perioperative RNs
should review the complete guideline for additional information and for guidance when writing and updating policies and
procedures.
Key takeaways from the AORN Guideline for surgical attire
include the following:
Scrub attire may be made of antimicrobial fabric.
Jewelry (eg, earrings, necklaces, bracelets, rings) that cannot
be contained or conned within the scrub attire should not
be worn in the semirestricted or restricted areas.
When in the restricted areas, all nonscrubbed personnel
should completely cover their arms with a long-sleeved scrub
top or jacket.
Cell phones, tablets, and other personal communication or
hand-held electronic equipment should be cleaned with a
low-level disinfectant according to the manufacturers instructions for use before and after being brought into the
perioperative setting.
Scrub attire and cover apparel should be laundered in a
health careeaccredited laundry facility after each daily use
and when contaminated (Figure 1).
190 j AORN Journal
February 2015, Volume 101, No. 2
SCENARIO
Nurse B and Nurse N have been assigned to work in orthopedic room #3. The rst patient is a 71-year-old man
undergoing a total hip arthroplasty (THA) procedure. Nurse
B dons a clean two-piece scrub suit in the designated dressing
room before entering into the semirestricted and restricted
areas of the surgical suite. She tucks the top into the pants
and secures the waist to help prevent dispersal of skin cells
into the air. The scrub attire used at the facility is made of a
tightly woven fabric with antimicrobials incorporated into the
bers. Nurse B is careful to ensure that the scrub attire does
not come in contact with the oor or other surfaces that
could be contaminated.
Nurse B puts on clean shoes that she wears only when working
in the OR. To comply with Occupational Safety and Health
Administration requirements for foot protection,3 she wears
shoes that have low heels and nonskid soles to help reduce
the chance that she will slip and fall and that have closed
toes and backs to help prevent injury from dropped items
and exposure to blood or body uids. Knowing that she is
scrubbing in on a THA procedure in which she anticipates
exposure to gross contamination with irrigation, Nurse B
also dons protective shoe covers.
Nurse B removes her rings and secures them to her necklace,
which she tucks inside her scrub top. She also removes her
watch and secures it with a safety pin inside her cover jacket
pocket. She dons a clean surgical bouffant cap that connes all
her hair and covers her ears and the nape of her neck. She
ensures that her earrings are fully enclosed by the cap.
Nurse B secures her identication badge directly to her scrub
top so it will be visible to patients and other health care providers. She does not wear her badge on a lanyard because
lanyards can be contaminated with microorganisms.4 She puts
on a surgical mask with an attached eye shield that covers her
mouth and nose. When securing the mask, she ensures that the
mask does not vent at the sides.
In the OR, she meets Nurse N, who is circulating for the
procedure. Nurse N wears a long-sleeved jacket that
completely covers her arms. The jacket is snapped closed up
the front and ts closely to her arms and torso to prevent the
edges of the jacket from potentially contaminating the surgical
site when she preps the patient. Together, they set up the room
for the procedure. After Nurse B has scrubbed in for the
procedure, she dries her hands and dons a sterile gown and
gloves using sterile technique. Meanwhile, Nurse N goes to the
preoperative area to assess the patient.
www.aornjournal.org
Guideline Implementation: Surgical Attire
Figure 1. Key takeaways from the AORN Guideline for surgical attire.
The THA implant representative arrives at the hospital. He
reports to the OR supply technician to check in a variety of
implants. They remove the implants from the cardboard boxes
and stack them on a clean cart before taking them into the OR
supply room. The implant representative veries that all
implants and implant supplies are correctly listed on the inventory list in his electronic tablet. After the implant representative changes into appropriate surgical attire, the supply
technician helps him clean his tablet with a low-level disinfectant before the representative takes the tablet into the
OR suite.
During the procedure, the implant representative refers to his
tablet several times to select the appropriate implants and
ancillary implant supplies. The procedure is performed
without incident. The implant representative cleans his tablet
with low-level disinfectant and performs hand hygiene again
after he leaves the OR suite.
www.aornjournal.org
After the procedure, Nurse B removes and disposes of her

sterile scrub gown and then removes her mask, handling it
only by the mask ties, and her shoe covers. She discards them
in the appropriate receptacles and performs hand hygiene. At
the end of the day, Nurse B goes to the dressing room,
removes her scrub attire, and places the attire in a designated
container from which it will be picked up and sent to the
health careeaccredited laundry facility.
KEY TAKEAWAYS DISCUSSION

The key takeaways from the AORN Guideline for surgical
attire address scrub attire fabric, jewelry, covering the arms in
the restricted area, electronic communication devices in the
OR, and using a health careeaccredited laundry facility. These
takeaways do not cover the entire guideline. Rather, they help
the reader focus on important or new information that should
be implemented into perioperative practice.
AORN Journal j 191
CowperthwaitedHolm
Resources for Implementation
Guidelines Implementation: Surgical Attire web page.

AORN, Inc. http://www.aorn.org/Topics_of_Interest/
Aseptic_Practice/Surgical_Attire/.
AORN Syntegrity Framework. AORN, Inc. http://
www.aorn.org/syntegrity.
ORNurseLinkTM. http://ornurselink.aorn.org.
Perioperative Competency Verication Tools and Job
Descriptions [CD-ROM]. Denver, CO: AORN, Inc;
2014. http://www.aorn.org/CompetencyTools.
Policy and Procedure Templates [CD-ROM]. 3rd ed.
Denver, CO: AORN, Inc; 2013. http://www.aorn.org/
Books_and_Publications/AORN_Publications/Policy_
and_Procedure_Templates.aspx.
The Roadmap to ASC Compliance [CD-ROM]. Denver,
CO: AORN, Inc; 2012. https://www.aornbookstore.org//
Product/product.asp?skuMAN543&dept_id1.
Syntegrity is a registered trademark and ORNurseLink is a
Web site access veried December 11, 2014.
Antimicrobial Fabric
Fabrics used for scrub attire should be tightly woven, low linting,
stain resistant, and durable.2(p99) In the scenario, Nurse B dons
scrub attire made with an antimicrobial fabric. Evidence
indicates that bacteria and fungi may not adhere to scrub
clothing made of a fabric that has antimicrobials processed into
the yarn.5-11 Researchers have found signicant reductions in
microorganisms, including Staphylococcus aureus,8-11 Klebsiella
pneumoniae,10 Escherichia coli,8,9 Pseudomonas aeruginosa,8,9 and
Morganella morganii,9 on fabrics treated with antimicrobials
compared with untreated fabrics. Research is needed to help
determine whether having the perioperative team wear scrub
clothes made of these fabrics can help reduce a patients risk for
developing an SSI.
Jewelry
Wearing jewelry has been found to increase bacterial counts on
the skin.12-18 Nurse B removes and secures her rings and watch
and covers her earrings in accordance with the facilitys policy.
Research supports removing rings, removing or containing
watches, and covering ear and nose piercings with head coverings and masks, respectively.12-18
Long-Sleeved Scrub Tops or Jackets

In the restricted areas, nonscrubbed personnel should wear a
long-sleeved scrub top or jacket to help contain shed skin
192 j AORN Journal
What Else Is in the Guideline?
Read the AORN Guideline for surgical attire1 to learn

what the evidence says about the following:
What is the primary source of bacteria dispersed into the
air of the OR or procedure room? (Recommendation
I.b.)
When should health care personnel change into street
clothes? (Recommendation I.e.)
Does wearing cover apparel protect scrub attire from
contamination? (Recommendation I.f.)
How should briefcases, purses, or backpacks that will be
taken into the OR be treated? (Recommendation I.l.)
Why should reusable scrub attire that has been worn not
be stored in a locker? (Recommendation II.b.4.)
When should personnel remove their surgical head
coverings? (Recommendation III.a.2.)
1. Guideline for surgical attire. In: Guidelines for Perioperative
Practice. Denver, CO: AORN, Inc; 2015:97-120.
squames and bacteria. More than 10 million particles are shed

from skin each day,19 and one study found that any organism
present on the skin (eg, Propionibacterium acnes, methicillinresistant Staphylococcus epidermidis) can be dispersed into the
air.20 Airborne bacteria shed from health care providers skin
can reach the surgical site.21 In the scenario, Nurse N wears
a long-sleeved jacket in the OR. This will help prevent skin
squames from her arms from dropping onto the surgical site
while she is performing the preoperative patient skin prep.
The jacket ts closely to her body and is snapped closed up
the front to prevent the edges of the jacket from potentially
contaminating the surgical site or other sterile areas.
Personal Communication Devices

Cell phones, tablets, and other personal communication devices may be contaminated with potentially pathogenic microorganisms that could be transferred to patients via the
health care providers hands. Reducing the numbers of microorganisms on these devices could reduce the patients risk
for developing an SSI.
The implant representative required the use of an electronic
tablet for inventory during the procedure, so the OR supply
technician ensured that the implant representative cleaned the
tablet with low-level disinfectant according to the manufacturers instructions for use and performed hand hygiene before
and after taking it into the OR suite. Researchers have recommended regular cleaning for devices brought into a health
care setting.12,22-33
www.aornjournal.org
Guideline Implementation: Surgical Attire
Health CareeAccredited Laundry Facility

Reusable scrub attire should be laundered at a health caree
accredited laundry facility after each daily use and when
contaminated.2(p109) Although the evidence comparing
home laundering and health careeaccredited facility
laundering conicts, some evidence indicates that pathogenic
organisms on scrub attire could be brought into the home
or community if clothing is removed from the health
care facility and taken home for laundering.34-36 In addition,
patients and others could be at risk if home laundered
scrub attire is not effectively decontaminated. Home
washing machines can also become contaminated with
bacteria.37,38
Home laundering practices are not subject to quality monitoring, and home washing machines may not have the
adjustable parameters or controls required to achieve the
necessary thermal measures (eg, water temperature); mechanical measures (eg, agitation); or chemical measures (eg, capacity
for additives to neutralize the alkalinity of the water, soap, or
detergent) to reduce microbial levels in soiled surgical
attire.2(p112) Health careeaccredited laundry facilities meet
industry standards for processing reusable textiles. In the
scenario, Nurse B places her reusable scrub attire in a
designated container and leaves it at the facility to be sent
out for laundering.
4.
5.
6.
7.
8.
9.
10.
11.
12.
CONCLUSION
As the patients advocates, perioperative nurses help ensure
that actions are performed to promote patient safety,
including reducing the patients risk for developing an SSI.
Perioperative RNs also should participate in multidisciplinary
teams to help ensure that policies and procedures for surgical
attire are up to date and in compliance with regulatory requirements and should help evaluate and select surgical attire
products for use in the facility. The AORN Guideline
for surgical attire is an evidence-based resource that perioperative RNs can use to help inuence safe perioperative practice.
References
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2. Guideline for surgical attire. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015:97-120.
3. 29 CFR x1910.136. Personal protective equipment: occupational
foot protection. Occupational Safety and Health Administration.
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Kotsanas D, Scott C, Gillespie EE, Korman TM, Stuart RL. Whats
hanging around your neck? Pathogenic bacteria on identity badges
and lanyards. Med J Aust. 2008;188(1):5-8.
Bauer J, Kowal K, Tofail SAM, Podbielska H. MRSA-resistant
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Sun G, Qian L, Xu X. Antimicrobial and medical-use textiles. Textile
Asia. 2001;32(9):33-35.
Rajendran R, Radhai R, Kotresh TM, Csiszar E. Development of
antimicrobial cotton fabrics using herb loaded nanoparticles. Carbohydr Polym. 2013;91(2):613-617.
Kasuga E, Kawakami Y, Matsumoto T, et al. Bactericidal activities
of woven cotton and nonwoven polypropylene fabrics coated with
hydroxyapatite-binding silver/titanium dioxide ceramic nanocomposite Earth-plus. Int J Nanomed. 2011;6:1937-1943.
Mariscal A, Lopez-Gigosos RM, Carnero-Varo M, FernandezCrehuet J. Antimicrobial effect of medical textiles containing bioactive bres. Eur J Clin Microbiol Infect Dis. 2011;30(2):227-232.
Chen-Yu JH, Eberhardt DM, Kincade DH. Antibacterial and laundering properties of AMS and PHMB as nishing agents on fabric
for health care workers uniforms. Clothing Text Res J. 2007;
25(3):258-272.
Bearman GM, Rosato A, Elam K, et al. A crossover trial of antimicrobial scrubs to reduce methicillin-resistant Staphylococcus
aureus burden on healthcare worker apparel. Infect Control Hosp
Epidemiol. 2012;33(3):268-275.
Saxena S, Singh T, Agarwal H, Mehta G, Dutta R. Bacterial
colonization of rings and cell phones carried by health-care providers: are these mobile bacterial zoos in the hospital? Trop Doct.
2011;41(2):116-118.
Bartlett GE, Pollard TC, Bowker KE, Bannister GC. Effect of jewelry
on surface bacterial counts of operating theatres. J Hosp Infect.
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Field EA, McGowan P, Pearce PK, Martin MV. Rings and watches:
should they be removed prior to operative dental procedures?
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Kelsall NKR, Griggs RKL, Bowker KE, Bannister GC. Should nger
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Jeans AR, Moore J, Nicol C, Bates C, Read RC. Wristwatch use
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Salisbury DM, Hutlz P, Treen LM, Bollin GE, Gautam S. The effect
of rings on microbial load of health care workers hands. Am J
Infect Control. 1997;25(1):24-27.
Khodavaisy S, Nabili M, Davari B, Vahedi M. Evaluation of bacterial
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215-218.
Noble WC. Dispersal of skin microorganisms. Br J Dermatol. 1975;
93(4):477-485.
Benediktsdottir E, Hambraeus A. Dispersal of non-sporeforming
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21. Tammelin A, Ljungqvist B, Reinmuller B. Comparison of three
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bacteria: a prospective observational study. Patient Saf Surg.
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22. Datta P, Rani H, Chander J, Gupta V. Bacterial contamination of
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23. Kilic IH, Ozaslan M, Karagoz ID, Zer Y, Davutoglu V. The microbial
colonisation of mobile phone used by healthcare staffs. Pak J Biol
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24. Albrecht UV, von Jan U, Sedlacek L, Groos S, Suerbaum S,
Vonberg RP. Standardized, app-based disinfection of iPads in a
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25. Al-Abdalall AH. Isolation and identication of microbes associated
with mobile phones in Dammam in eastern Saudi Arabia. J Family
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26. Brady RR, Chitnis S, Stewart RW, Graham C, Yalamarthi S,
Morris K. NHS connecting for health: healthcare professionals,
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27. Tekerekoglu MS, Duman Y, Serindag A, et al. Do mobile phones of
patients, companions and visitors carry multidrug-resistant hospital
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28. Sadat-Ali M, Al-Omran AK, Azam Q, et al. Bacterial ora on cell
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29. Akinyemi KO, Atapu AD, Adetona OO, Coker AO. The potential role
of mobile phones in the spread of bacterial infections. J Infect Dev
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30. Basol R, Beckel J, Gilsdorf-Gracie J, et al. You missed a spot!
Disinfecting shared mobile phones. Nurs Manage. 2013;44(7):
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31. White S, Topping A, Humphreys P, Rout S, Williamson H. The
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32. Ustun C, Cihangiroglu M. Health care workers mobile phones: a
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33. Singh A, Purohit B. Mobile phones in hospital settings: a serious
threat to infection. Occup Health Saf. 2012;81(3):42-44.
34. Gerba CP, Kennedy D. Enteric virus survival during household
laundering and impact of disinfection with sodium hypochlorite.
Appl Environ Microbiol. 2007;73(14):4425-4428.
35. Lis DO, Pacha JZ, Idzik D. Methicillin resistance of airborne
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contact with a hospital environment. Am J Infect Control. 2009;
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36. Twomey CL, Beitz H Johnson BJ. Bacterial contamination of surgical scrubs and laundering mechanisms: infection control implications. Infect Control Today. http://www.arta1.com/cms/uploads/
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%20Laundering%20Mechanisms_%20Infection%20Control%20
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37. Wright SN, Gerry JS, Busowski MT, et al. Gordonia bronchialis
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Liz Cowperthwaite, BA
is the senior managing editor at AORN, Inc, Denver, CO.
Ms Cowperthwaite has no declared afliation that could
Rebecca L. Holm, MSN, RN, CNOR

is the clinical editor for the AORN Journal, AORN, Inc,
Denver, CO, and an RN in perioperative services at Skyridge Surgery Center, Lone Tree, CO. Ms Holm has no
declared afliation that could be perceived as posing a
potential conict of interest in the publication of this
article.
www.aornjournal.org
Surgical Team Mapping:

Implications for Staff Allocation
and Coordination
MARK SYKES, MBus, BPsych (HONS); BRIGID M. GILLESPIE, PhD, RN;
WENDY CHABOYER, PhD, RN; EVELYN KANG, MPH, RN
ABSTRACT
Perioperative team membership consistency is not well researched despite being essential in reducing
patient harm. We describe perioperative team membership and stafng across four surgical specialties
in an Australian hospital. We analyzed stafng and case data using social network analysis, descriptive
statistics, and bivariate correlations and mapped 100 surgical procedures with 171 staff members who
were shared across four surgical teams, including 103 (60.2%) nurses. Eighteen of 171 (10.5%) staff
members were regularly shared across teams, including 12 nurses, ve anesthetists, and one registrar.
We found weak but signicant correlations between the number of staff (P < .001), procedure start
time (P < .001), length of procedure (P < .05), and patient acuity (P < .001). Using mapping, personnel
can be identied who may informally inuence multiple team cultures, and nurses (ie, the majority
of team members in surgery) can lead the development of highly functioning surgical teams. AORN J
101 (February 2015) 238-248. AORN, Inc, 2015. http://dx.doi.org/10.1016/j.aorn.2014.03.018
Key words: operating room, social network analysis, surgery, teamwork, patient safety.
AORN, Inc, 2015
238 j AORN Journal
www.aornjournal.org
embers of surgical teams work interdependently to perform complex and varied tasks.1
Crucially, team performance often depends
on team members familiarity with each other and with
specic surgical routines.2 However, despite a growing body
of research to support the relationship between nurse stafng
and patient outcomes,3-6 few studies have examined stafng
in the OR. Several researchers have described the critical role
that membership in surgical teams has in dening team
performance.7-10 To foster highly functioning surgical teams,
consistency in team membership is considered important in
reducing the potential for error and patient harm. However,
in reality, the stability of team membership is often a luxury
as teams comprising nurses, surgeons, anesthesia personnel,
and surgical technicians are frequently ad hoc.11
Managing surgical teams that have dynamic membership can
be made easier by visualizing team membership using a
technique developed for sociometric analysis. Sociometry is a
method that can be used to map team membership to
discover existing relationships among these individuals and
for disclosing the structure of the group itself.12,13 Using
data sets from the electronic health record (EHR) for purposes beyond clinical documentation, billing, and administration is rapidly increasing.14 Best of all, these data are
routinely collected as part of the OR electronic register
that records surgical information about the surgical
procedure details, staff attendance, and skill mix. Elements of
the EHR can be used as a basis for a sociometric analysis
to map team membership. Sociometric maps are useful
management tools when implementing procedural or team
changes as they can be enhanced to reect people, process, and
technological perspectives. We used sociometric analysis to
describe team membership and stafng characteristics across
four surgical specialties.
STATEMENT OF PURPOSE
This project was part of a larger multicenter observational
study that described the nontechnical skills (eg, communication skills, teamwork) used by surgical teams in two metropolitan Australian hospitals. Based on the results of the
structured observations, this larger study sought to develop a
team training intervention to improve team members
nontechnical skills to enhance team cohesiveness and performance. We present the results of using a sociometric analysis
of team structures at one of the participating hospitals. The
aim of this correlational substudy was to map team membership using social network analysis and describe relationships
between case-related variables across four surgical specialties.
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Surgical Team Mapping
RESEARCH QUESTIONS
We asked the following questions to guide this study:
What proportion of individual staff members involved in
surgery are RNs, anesthesia professionals, surgeons, and
registrars/residents across four surgical teams?
How many team members are shared across four surgical
teams?
What are the relationships between the procedure-related
variables of start times, the total number of staff members
per procedure, length of procedure, and patient acuity?
Length of procedure, patient acuity (ie, illness severity), and
the number of staff members involved in each procedure are
considered indicative of the complexity of the surgery11,15 and
may inuence the interpersonal interactions of the team
members involved and team performance.10,15,16 Consequently, inclusion of these procedure-related variables allowed
us to consider team membership in the broader context of OR
stafng, the different surgical specialties and types of surgeries
performed, and patient-related factors.
SIGNIFICANCE TO NURSING
There is limited research that focuses on mapping team membership and describing the interdisciplinary stafng characteristics of surgical teams using a social network analysis framework.17
We used social network analysis to identify team structures based
on the regularity of membership to gain insight into the relations
among team members and social network structures. Previous
research has found that team membership and the quality of
intergroup and interdisciplinary communications potentially
can contribute to the quality of patient care.11,18
LITERATURE REVIEW
All surgical procedures require a high level of coordination between
various individuals from different professional disciplines.15 The
complexity of a surgical procedure affects every aspect of team
performance.15 Procedural complexity encompasses aspects such
the type of surgeries performed and their associated risks (ie,
postoperative complications), patient acuity and pre-existing
comorbidities, and the surgical technologies used.10,15 Further,
procedural complexity determines the time to complete the
procedure and who should be assigned to the surgical team.15,19
In relation to how team membership, roles, and tasks interface,
most team members view the consultant surgeon as the team
leader, while the surgical registrar or assistant surgeon, RN
circulator, and scrub person follow and support the surgeon.19
The RN circulator supports the scrub person and other team
AORN Journal j 239
Sykes et al
members as needed while the anesthesia professional

anesthetizes or sedates the patient and maintains his or her
stability during surgery. Clearly, surgical teams are required
to collaborate and coordinate their performance in a manner
that ensures that the combined experience of all members is
shared and optimized.19 For ideal performance, surgical
teams need to be more than merely groups of individuals.
Expert surgical team members characteristically have a shared
understanding of each others tasks, roles, and responsibilities,
obtained through developing a shared mental model of the work
they perform.19 Surgical team familiarity is cultivated over time
and gained through regularly working with other members of a
dedicated team (ie, a group of individuals who share a similar
mental model).8 Shared mental models enable individuals to
adapt quickly and coordinate their actions based on their
underlying knowledge of each other and the situation in
which they nd themselves.1 Nevertheless, the majority of
In general health care, the formal structure of a team is often

known and its hierarchy can be an approximate guide to who
is able to inuence the team. However, in highly dynamic
team environments such as the OR, the formal team structure
is poorly understood or is uid depending on the task. In this
context, a sociometric map can provide a snapshot of the team
structure and allocation for a specied duration. By comparing
a snapshot of team maps over several time periods, longitudinal
changes in team structure or attributes (eg, shifts in skill
proles of individual members and core membership ) can be
identied by nurse managers and educators.
Team maps can also assist managers in planning both cultural
changes within a team and process changes across teams. As
potential catalysts for change, individuals bring both positive
and negative behaviors and work practices that shape team
culture. Positive work practices may be manifest in a team
members ability to diffuse tension during complex surgery,22,23
Expert surgical team members characteristically

have a shared understanding of each others
tasks, roles, and responsibilities, obtained
through developing a shared mental model of
the work they perform.
surgical teams are formed the day of surgery or, in emergent

situations, just moments before the patient is wheeled into
the OR. This results in teams that may not work regularly
together and can leave little time for information exchange
between the surgeon, anesthesia professional, and nurses.15,20
In the absence of regularity in team membership, it is
especially important to build an effective team through
collectively fostering good communication practices before a
procedure starts and during staff turnover.9,20
Mapping Surgical Team Membership

The use of sociometry to obtain knowledge about a group has the
potential to reveal informal team leaders, socially isolated team
members, and unofcial subgroups that emerge within teams.13,21
It is a powerful tool because it illustrates social interactions among
group members based on a chosen criterion, which may facilitate
understanding of a group. Sociometry is particularly useful in
revealing the links between individuals within the group.
240 j AORN Journal
organize and predict the equipment needs for surgical cases,24

assist and encourage others, value input from everyone, and
provide technical savvy.9 Less desirable attributes such as
withholding information,22,25 sabotaging others, a lack of
communication, and a lack of leadership reduce the teams
effectiveness9 and can compromise patient safety. In surgical
teams, the ability of individuals to act as inuential change
agents is strengthened through collegial relationships
developed over time, active and enthusiastic participation in
the organizations institutional initiatives, and knowledge of
the clinical setting and the patients unique needs.
METHODS
For our design, we used a descriptive, correlational design. We
were interested in using social network analysis to map team
membership across four surgical teams and to describe relationships among length of procedure, patient acuity, and the
number of staff involved in each procedure.
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Setting and Sample

The setting for this study was a large tertiary-care Australian
hospital. During the study period, personnel at this 450-bed
metropolitan hospital performed approximately 17,000 elective
surgeries in all specialties except cardiac and transplantation
surgery. We purposively selected four surgical teams based on the
diversity of surgeries in each surgical specialty and team members willingness to participate. At this hospital, surgical teams
were composed of anesthesia professionals including anesthetists, surgeons and their registrars/residents, and RNs who
circulated and scrubbed and practiced as anesthetic assistants. In
this OR department, surgical technicians are not employed.
Data Collection and Measures

We derived data retrospectively using the electronic database
Operating Room Management Information System (ORMIS),
Table 1 provides the conceptual and operational denitions

for the procedure variables we analyzed in this study. We
veried the data obtained through ORMIS using data
quality checks to identify any problems with missing or
incorrectly coded data. We removed personal identiers
and reassigned anonymous identiers to staff members
and patients.
Institutional Approval
The university and the Human Research Ethics Committee of
the participating hospital granted institutional approval.
Because we collected patient data retrospectively, there was no
requirement to seek patients permission to access their
ORMIS records. After ethics approval, we sought permission
to access the ORMIS database from the Director-General of
the Health Department (Queensland), as required by the
In surgical teams, the ability of individuals to act

as inuential change agents is strengthened
through collegial relationships developed over
time, active and enthusiastic participation in the
organizations institutional initiatives, and
knowledge of the clinical setting and the
patients unique needs.
and we collected data during 2012. We accessed the OR

attendance records based on 100 surgical procedures electronically recorded in the ORMIS database across the four
selected surgical teams. We identied teams by the attending
consultant surgeon, and we tracked each team member who
worked with the surgeon, the number of procedures for which
team members were present, and the time that each procedure
took to complete. We collected data over four months that
included the procedure, patient, and individual staff categories
(ie, nurses, registrars, consultants). Data derived about the
procedures included variables related to procedure type,
length of procedure in minutes, and the number of staff
members present.15 At the staff level, data included clinical
role, total time spent in each procedure, and the times
individuals signed in or out of procedures. Patient-level data
included the patients American Society of Anesthesiologists
(ASA) status,10 type of surgery, and the type of anesthetic.
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Public Health Act (2005). We did not record patients personal information, such as names and dates of birth.
Data Analysis
For data analysis, we obtained OR attendance records through
ORMIS and created an Excel spreadsheet, where we transformed the coded data into a format that could be interpreted by
sociometric software.26 We used GephiTM software26 to generate
a map of team membership. Statistical analysis of stafng
networks was essentially descriptive. In the Gephi program, we
split data into two sets: nodes and edges. Node data
formed a discrete entity, consisting of either individuals,
collections of individuals, or an event (ie, individual surgical
procedure). In constructing our team membership map, node
data were based on individuals and procedures. We generated
nodes from a list of surgical procedures and individuals who
AORN Journal j 241
Sykes et al
Table 1. Conceptual and Operational Denitions for Case Variables

Case Variable
Procedure Start Time
Conceptual Denition
Operational Denition
Time of the rst incision (ie, scalpel to skin)1
Time, recorded using the 24-hour clock
Procedural Complexity
Length of Procedure
Time from skin preparation to application

Measured in minutes using the median
of nal dressing2
and interquartile range
Number of Staff Present
Each person assigned to a procedure throughout Count of total mumber of staff members
the duration of the procedure3
for each procedure tallied and a
median score obtained
Rating scores range from 1 to 5, with
Patients American Society A subjective measure of a patients underlying
1 completely healthy patient through
of Anesthesiologists4 Status
illness severity assigned by the anesthsia
to 5 moribund patient, not expected
Rating
professional.5 An indicator of a patients
to live beyond 24 hours
tness for surgery
References
1. Gillespie B, Chaboyer W, Fairweather N. Factors that inuence the expected length of operation: results of a prospective study. Qual Saf Health
Care. 2012;21(1):3-12.
2. Gillespie B, Chaboyer W, Fairweather N. Interruptions and miscommunications in surgery: an observational study. AORN J. 2012;95(5):576-590.
3. Cassera M, Zheng B, Martinec D, Dunst C, Swanstr
om L. Surgical time independently affected by surgical team size. Am J Surg. 2009;198:
216-222.
4. ASA Physical Status Classication System. American Socety of Anesthesiologists. https://www.asahq.org/clinical/physicalstatus.htm. Accessed
October 21, 2014.
5. Mazzocco K, Petitti DB, Fong KT, et al. Surgical team behaviors and patient outcomes. Am J Surg. 2009;197(5):678-685.
worked with a particular attending surgeon during a specic

period. The relationships between the nodes give a network its
structure. In this study, we allocated a unique staff identity
number to each individual.
We connected node data by edges, which represented either
undirected or directed contact with other team members
during the procedure. Edge data described the paired relationships between all team members in a single surgical
procedure. For instance, in a ctitious scenario, if there were
ve staff members involved in performing a surgical procedure,
the surgeon, assistant surgeon, scrub nurse, anesthesia professional, and circulating RN, the following undirected edges
exist; surgeon/assistant surgeon, surgeon/anesthesia professional, assistant surgeon/anesthesia professional, scrub nurse/
surgeon, and RN circulator/scrub nurse. The relationship
edges are described as undirected (ie, the relationship can ow
either way and is not necessarily initiated by one person)
because saying the surgeon/assistant surgeon worked together
is identical to saying the assistant surgeon/surgeon worked
together. When tracking the team interactions, the team map
shows lines that are thicker when individuals spend more time
together, talk to each other more often, engage in more teamrelated communication, or instruct, discipline, or praise
each other.13
We analyzed case- and patient-level data using the program IBM
SPSS Statistics 20 for Windows to tally categorical data (ie,
total number of staff involved in each case, staff role, ASA status)
242 j AORN Journal
and measured length of procedure in minutes. We calculated the

median and interquartile range (IQR) for length of procedure.
We used Kendalls tau-b (s) rank correlation to assess bivariate
relationships between procedure start times, total number of
staff involved, length of procedure, and patient illness severity
rating (ASA). Our decision to use this nonparametric statistic
was based on the level and distribution of the data and the sample
size. We considered P < .05 signicant.
RESULTS
We analyzed case- and patient-related data for 25 procedures
in general, thoracic, orthopedic, and pediatric surgical specialties (n 100). The total number of individuals in the
Table 2. Participants in Surgical Procedures Across
Four Specialties
All Participants
Number (%)
103
Type
RN
53
Anesthesia personnel
15
Surgical registrar/resident
Participants Shared Regularly Between Teams
12 (66.6)
RN
5 (27.8)
Anesthesia personnel
1 (5.6)
Surgical registrar
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Figure 1. A visual depiction of the combined individual team maps that provides a complete picture of team
relationships both within and across the four surgical specialties studied.
combined networks was 171. Of the 171 staff working within
these four specialties, 103 (60.2%) RNs, 53 (31.0%) anesthesia professionals, and 15 (8.8%) surgical registrars or residents (Table 2) were shared across all networks. Figure 1
depicts the combined individual team maps to provide a
complete picture of team relationships both within and
across the four surgical specialties. Across these teams, core
membership was characterized by members who regularly
worked together and also included members who were
shared across a number of the teams.
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The team map indicates that 12 RNs, one surgical registrar, and
ve anesthesia professionals were regularly shared across the four
surgical specialities (18/171; 10.5%), over the 100 procedures
(Table 2). The thicker edges (ie, lines) between members of the
pediatric and thoracic teams suggest that those members spent
more time working together. Data for the number of core
team members across each specialty indicated that the team
with the greatest number of core members was the thoracic
team (average four members), while the general surgery team
had the least number of core members for any given
AORN Journal j 243
Sykes et al
here has enabled us to depict team membership over a fourmonth period relative to core staff and peripheral team
members across four surgical specialties. These results build on
previous research that has focused on interdisciplinary stafng
characteristics17 and augments our understanding of team
structures among interacting health professionals and the
relationships between stafng variables. As such, this study
contributes to the current paucity of research in this
emerging area.
Table 3. Median Length of Procedure Time Across

Four Specialties
Surgical
Team
Range in Minutes
Median Interquartile
(Minutes)
Range
Minimum Maximum
General
Surgery
90
123
23
621
Orthopedics
109
63
27
163
Pediatric
38
54
185
Thoracic
56
45
12
166
In the absence of a formal team structure, a team map can

conrm status and role allocation. Ibarra and Andrews27
identied that formal organizational hierarchy and informal
social networks contribute to team attitudes. In this study, the
team map shows four teams with a central connecting bridge
and a small outer ring. The outer ring is composed of
individuals who are shared between two teams. The RNs at
the center of the map oat among all the teams, and their
team membership function may range from a disconnected
outlier (ie, a team member that may be infrequently allocated
to the team) to an integrating bridge (ie, thicker lines directed
toward the center of the diagram) between teams. Most of the
team members involved in surgery were RNs (60.2%)
(research question 1), which is not surprising given that nurses
comprise the largest staff prole in many OR departments.
procedure with only one regular member (eg, usually an RN)

present. During longer cases (ie, longer than four hours),
there were as many as six team member changeovers, most of
which involved nurses in circulatory and/or scrub roles.
The average length of surgery per procedure varied across each
specialty (Table 3). Orthopedics procedures tended to take
longer than procedures in the other specialties, with the
median length of surgery being 109 minutes (IQR 63).
Table 4 shows results of the bivariate correlations. The
length of procedure was inversely correlated with start time,
suggesting that longer procedures tended to be scheduled
earlier in the day (s .13; P < .05). Not surprisingly, the
longer the procedure, the more staff members were involved
(s .13; P < .001). Patient illness severity measured using
the ASA rating was weakly but signicantly correlated with
the length of procedure (s .18; P < .001).
Only 10.5% of surgical staff members were shared across the

four teams (research question 2). However, in a previous
study, the authors reported that up to 55% of staff members
crossed over between two networks (ie, general surgery,
neurosurgery teams).17 In our study, RNs comprised 66.5%
(12/18) of the core staff members who were shared across all
four teams (research question 2). This proportion was lower
in a 2011 study that examined OR stafng characteristics
and team membership, in which 56% of core staff members
DISCUSSION
This is one of the rst studies to describe team membership in
surgery using sociometric methods. The team map generated
Table 4. Correlations of Case Variables Across Four Surgical Specialties
Case Variable
Procedure Start Time
Length of Procedure
Number of S Members
Patients ASA Ratings
a
b
Length of
Procedure
in Minutes
Start
Time
Number of
Staff Members
Patients
American Society
of Anesthesiologists
(ASA)1 Rating Scores
1
0.03
0.16
0.13b
0.19
0.18
1
0.07
Kendalls tau-b (s) rank correlation is signicant at P < . 05 level.

Correlation is signicant at P < .001 level.
Reference
1. ASA Physical Status Classication System. American Society of Anesthesiologists. https://www.asahq.org/clinical/physicalstatus.htm. Accessed
October 21, 2014.
244 j AORN Journal
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KEY TAKEAWAYS FOR CLINICAL PRACTICE

Using Sociometric Analysis to Map Team Membership
WHY DID WE DO THIS RESEARCH?
We wanted to gain a better understanding of surgical team membership and how it affects OR stafng over time.
We used sociometric analysis to develop a simple visual map to plot staff team composition and attendance.
WHAT DID WE FIND?
Electronic health record data are suitable for mapping team membership over time.
Studying four diverse surgical teams (general, thoracic, orthopedic, pediatric), 25 surgical procedures, and 171
participating staff members, we found that 10% of team members were shared between teams and 67% of team
members were RNs.
Team function was affected in relation to the number of staff members who participated in a procedure, procedure
start time, length of case, and patient acuity.
HOW CAN CLINICIANS USE THESE RESULTS?
Clinicians: Core nursing personnel shared across teams may be better able to monitor team climate within the
team and are well positioned to take on formal and informal leadership roles in surgical teams.
Managers: Analyzing surgical team patterns over time leads to better understanding of team stability, team-focused
absences, and skill deciencies. Team maps may identify established senior personnel who are members in more
than one team and who can facilitate consistent improvement practices across teams. Ensuring the continuity and
regularity of team membership improves team function and patient care.
Educators: Team maps could identify team members requiring further education and core team members or
specialists who could mentor new or inexperienced personnel to specic skills required in a surgical speciality.
Sykes M, Gillespie BM, Chaboyer W, Kang E. Mapping team membership in surgery: implications for staff allocation and coordination.
AORN J. 2015;101(2):238-248. Copyright AORN, Inc, 2015.
www.aornjournal.org
were RNs.17 Sociometrically, the RNs in the center of the

team map are likely to act as pulse-takers. That is, they are
able to gauge the status of information and attitudes within
the network, but are less likely to be inuential.28 However,
unlike the surgeons at the hub of the teams, pulse-takers
have greater opportunity to formally engage with members
of the entire network.21 The outer ring of our map is
composed of integrated team members who in this case tend
to hold higher organizational status. These individuals are
potentially connectors who can control the information
between groups and inuence more than one team.
In terms of the relationships between procedure-related variables (research question 3), the positive correlation between
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patients ASA status, an indicator of illness severity, and the

length of procedure is unsurprising. Conceivably, the patients
preoperative condition is more likely to increase the procedures complexity and length and inuence team dynamics.
During eld work, we observed purposeful and deliberate
patient- and case-related communications between consultant
surgeons and anesthesia professionals when the patient was
considered more ill (ie, ASA scores 3). While RNs were not
always privy to these discussions, those with more experience
and seniority were proactive and assertive and often asked
questions about the need for additional procedure- or
anesthetic-related equipment. During procedure preparations,
senior RNs communicated procedure-related information to
the more junior RNs in the room. In this way, senior RNs
AORN Journal j 245
Sykes et al
acted as vital conduits for information transfer and enabled

others to be better prepared.
Previous researchers have demonstrated the inverse relationship
between stafng numbers, procedure-related variables, and procedure start times.17 The results of our study are similar and
demonstrate an inverse relationship between the number of staff
members and procedure start time (research question 3), and
this result is of some concern. The effect of having fewer core
team members available for procedures that start later in the day
may lead to variations in the quality of patient care provided.
However, this result may be a function of specialization and skill
mixdboth of which affect the availability of staff members for
scheduled or emergency procedures. This may also partly explain
why up to 12 of 103 (11.6%) RNs were shared across the four
specialties. Generally, these pulse-takers were experienced,
versatile, and able to move seamlessly among the four specialties.
In establishing whether a relationship exists between personnel
turnover and total number of personnel involved (research
develop comprehensive shared mental models in relation to

goals and tasks. Clearly, high staff turnover and short-term
involvement of staff members during a procedure require
better communication strategies to keep them updated with
the progress of the procedure.15
Limitations
We acknowledge that there are several limitations to using
this form of analysis to describe surgical team membership.
First, we have used sociometric analysis in a nontraditional
way. We did not measure typical attributes such as
interpersonal relations between individuals, the number of
times that members communicated with each other, or the
specic types of communications that occurred among
members. Although team maps provide useful insights about
team structure, they do not measure teamwork. Second, the
position of team members on the map was determined by
the total time worked together calculated in operating
minutes in each of the surgical specialties. Ultimately, it is a
Information sharing enables all team members

to develop a comprehensive, shared mental
model.
question 3), we found a commensurate increase in turnover

with increased staff numbers per procedure during longer
surgeries. While increasing team size brings in expertise that
may be necessary to achieve the desired goals, larger teams
increase barriers to communication, making it more difcult
for team members to develop and maintain shared mental
models.7,15 In our study, increases and/or changes in team
membership were supported by the observations recorded in
the eld notes that our research team member took during the
observational phase of our larger study. For instance, particularly in general surgery, we observed that as many as four
nurses (including relief staff) were commonly assigned to a
single role (ie, scrub or circulating roles) during procedures
lasting up to six hours (eg, Whipple procedures, liver resections). Although it may be argued that personnel turnover is
needed to maintain a high level of vigilance, frequent nursing
personnel turnovers during complex procedures may
contribute to degradation in team communication and lead to
distraction and a loss of focus.15 Conversely, involvement in
the entirety of the procedure enables team members to
246 j AORN Journal
graphical representation of a formal team structure that is

imposed by a work schedule and speciality needs. Third, we
relied on secondary data derived retrospectively from one
hospitals database, which may not be as accurate as using
contemporaneous data collection methods. Nonetheless, we
also collected prospective observational data to conrm
surgical team details. Finally, we did not attempt to relate
our results to patient outcomes. For this, we would need a
much larger sample size.
Implications
Our innovative approach to using routinely collected data to
map team membership enables managers and leaders to visually see stafng patterns with the goal of improving decision
making around change management interventions, staff allocation, and team balance. First, by identifying team members
who are shared between surgical teams, it is possible to identify
change champions who can effectively support change initiatives across multiple teams in a consistent manner. Nurses,
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who constitute the majority of team membership in the OR,

are well placed to assume leadership roles in the formation of
high-functioning surgical teams. Nurses can act informally to
convey group norms and work procedures that inuence surgical and anesthesia residents or other nursing personnel with
the potential to dene and inuence team culture across
multiple teams.
Second, team maps graphically differentiate nurses with a
strong team specialization or team neutrality. In the current
study, 12 of the 53 RNs we mapped regularly moved among
multiple teams. Team neutrality (ie, the ability to easily move
from one team to another) may highlight individuals who
possess wide skill repertoires, exibility, and versatility to move
among various surgical subspecialties. Conversely, those nurses
identied as being team specialists or core members of
particular surgical teams (eg, thoracic team) may be good
persons to teach new and inexperienced nurses the specic
skills required in a surgical speciality.
Third, the information gleaned through mapping team
membership allows nurse managers to obtain longitudinal data
in relation to planning ongoing skills development strategies
across each specialty area. Such information may inform staff
development initiatives around skill mix and create educational
opportunities for orienting novice nurses and providing the
opportunity to rotate through each specialty to gain essential
skill sets needed to practice safely in the OR environment.
Finally, because turnover during surgical procedures may be
unavoidable, protocols to ensure the deliberate and timely
exchange of important information about the patients condition, specic task requirements, and equipment for the
procedure are imperative. One approach is to develop strategies
that encourage individuals to pass on information to the newly
assigned team member before the procedure and during staff
turnover.15 Information sharing enables all team members to
develop a comprehensive shared mental model.16
CONCLUSION
Through mapping team membership, it is possible to enhance
our understanding of the stability of team membership over
time. Thus, team mapping may be useful in guiding decisions
around team and task allocation. Our results suggest that
stafng numbers increased with procedural complexity and
duration. Managers should identify and implement scheduling
practices to better facilitate the continuity and regularity of
team membership, especially for the nurses in the team, to help
ensure better outcomes for the patient by providing a more
cohesive better-functioning team.
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Acknowledgment: Dr Gillespie acknowledges the nancial

assistance of the Australian Research Council, Early Career
Discovery Fellowship Scheme.
Editors notes: Operating Room Management Information
System (ORMIS) is a registered trademark of Computer Sciences
Corporation, Middleton, MA; GephiTM software is a trademark
of the Gephi Consortium, Paris, France; IBM SPSS Statistics 20
for Windows is a registered trademark of the IBM Corp, Armonk,
Town of North Castle, New York. Windows and Excel are
registered trademarks of Microsoft, Redmond, WA.
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of organisational and individual factors on team communication
in surgery: a qualitative study. Int J Nurs Stud. 2010;47(6):
732-741.
3. Aiken LH, Sloane DM, Bruyneel L, et al. Nurse stafng and
education and hospital mortality in nine European countries: a
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4. Aiken LH, Clarke SP, Sloane DM, et al. Nurses reports on hospital
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5. Penoyer DA. Nurse stafng and patient outcomes in critical care: a
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stafng and patient outcomes: more about failure to rescue. J Nurs
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7. Macmillan J, Entin E, Serfaty D. Communication overhead: the
hidden cost of team cognition. In: Salas E, Fiore S, eds. Team
Cognition: Understanding the Factors That Drive Process and
Performance. Washington, DC: American Psychological Association; 2004:61-82.
8. Gillespie BM, Chaboyer W, Fairweather N. Interruptions and miscommunications in surgery: an observational study. AORN J.
2012;95(5):576-590.
9. Baker DP, Day R, Salas E. Teamwork as an essential component of
high-reliability organizations. Health Serv Res. 2006;41(4, pt 2):
1576-1598.
10. Mazzocco K, Petitti DB, Fong KT, et al. Surgical team behaviors
and patient outcomes. Am J Surg. 2009;197(5):678-685.
11. Gillespie BM, Chaboyer W, Fairweather N. Factors that inuence
the expected length of operation: results of a prospective study.
BMJ Qual Saf. 2012;21(1):3-12.
12. Fields CD. Sociometry 1937. Soc Psychol Quart. 2007;70(4):
326-329.
13. Lucius RH, Kuhnert KW. Using sociometry to predict team performance in the work place. J Psychol. 1997;131(1):21-32.
14. Hayrinen K, Saranto K, Nykanen P. Denition, structure, content,
use and impacts of electronic health records: a review of the
research literature. Int J Med Inform. 2008;77(5):291-304.
AORN Journal j 247
Sykes et al
15. Cassera MA, Zheng B, Martinec DV, Dunst CM, Swanstrom LL.
Surgical time independently affected by surgical team size. Am J
Surg. 2009;198(2):216-222.
16. Gillespie BM, Gwinner K, Fairweather N, Chaboyer W. Building
shared situational awareness in surgery through distributed dialog.
J Multidiscip Healthc. 2013;6:109-118.
17. Anderson C, Talsma A. Characterizing the structure of operating
room stafng using social network analysis. Nurs Res. 2011;60(6):
378-385.
18. Lingard L, Regehr G, Cartmill C, et al. Evaluation of a preoperative
team brieng: a new communication routine results in improved
clinical practice. BMJ Qual Saf. 2011;20(6):475-482.
19. Catchpole K. Task, team and technology integration in the paediatric cardiac operating room. Prog Pediatr Cardiol. 2011;32(2):
85-88.
20. Gillespie BM, Gwinner K, Chaboyer W, Fairweather N. Team
communications in surgerydcreating a culture of safety.
J Interprof Care. 2013;27(5). 387-393.
21. Borgatti SP, Halgin DS. On network theory. Organization Science.
2011;22(5):1168-1181.
22. Riley R, Manias E. Foucault could have been an operating room
nurse. J Adv Nurs. 2002;39(4):316-324.
23. Lingard L, Reznick R, Epsin S, Regehr G, DeVito I. Team
communications in the operating room: talk patterns, sites of
tension, and implications for novices. Acad Med. 2002;77(3):
232-237.
24. Gillespie BM, Chaboyer W, Wallis M, Chang A, Werder H. Managing the list: OR nurses dual role of coordinator and negotiator.
ACORN J. 2009;21(1):14-19.
25. Gillespie BM, Wallis M, Chaboyer W. Operating theater culture:
implications for nurse retention. West Nurs Res. 2008;30(2):
259-277.
26. Bastian M, Heymann S, Jacomy M. Gephi: An Open Source
Software for Exploring and Manipulating Networks. 2009. https://
gephi.org/publications/gephi-bastian-feb09.pdf. Accessed October
24, 2014.
27. Ibarra H, Andrews SB. Power, social inuence, and sense making:
effects of network centrality and proximity on employee perceptions. Admin Sci Qtrly. 1993;38(2):277-303.
28. Hawkins J. Uncovering the hidden secrets of an organization.
Strategic HR Review. 2008;7(6).
248 j AORN Journal
Mark Sykes, MBus, BPsych (Hons)

is a research fellow at the NHMRC Research Centre for
Excellence in Nursing, Research Centre for Health Practice Innovation, at Grifth Health Institute, Grifth University, Gold Coast Campus, Queensland, Australia. Mr
Sykes has no declared afliations that could be perceived
as posing a potential conict of interest in the publication
of this article.
Brigid M. Gillespie, PhD, RN

is an associate professor at the NHMRC Research Centre
for Excellence in Nursing, Research Centre for Health
Practice Innovation, at Grifth Health Institute, Grifth
University, Gold Coast Campus, Queensland, Australia.
As a member of the Editorial Board of the AORN Journal
and as a recipient of the Australian Research Council,
Early Career Discovery Fellowship Scheme, Dr Gillespie
has declared an afliation that could be perceived as
posing a potential conict of interest in the publication of
this article.
Wendy Chaboyer, PhD, RN

is a professor and director at the NHMRC Research
Centre for Excellence in Nursing, Research Centre for
Health Practice Innovation, at Grifth Health Institute,
Grifth University, Gold Coast Campus, Queensland,
Australia. Dr Chaboyer has no declared afliations that
could be perceived as posing a potential conict of interest in the publication of this article.
Evelyn Kang, MPH, RN

is a senior research assistant at the NHMRC Research
Centre for Excellence in Nursing, Research Centre for
Health Practice Innovation, at Grifth Health Institute,
Grifth University, Gold Coast Campus, Queensland,
Australia. Ms Kang has no declared afliations that could
www.aornjournal.org
Back to Basics: Implementing
Evidence-Based Practice
LISA SPRUCE, DNP, RN, ACNS, ACNP, ANP, CNOR
2.2
www.aorn.org/CE
Approvals

completes this program can immediately print a certificate of
completion.
This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements.
Registered Nursing, Provider Number CEP 13019. Check with
your state board of nursing for acceptance of this activity for
relicensure.
Event: #15504
Session: #0001
The contact hours for this article expire January 31, 2018.
Purpose/Goal
To provide the learner with knowledge specific to implementing evidence-based practice.
Objectives
Conflict of Interest Disclosures

Lisa Spruce, DNP, RN, ACNS, ACNP, ANP, CNOR, has no
declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
The behavioral objectives for this program were created
by Helen Starbuck Pashley, MA, BSN, CNOR, clinical editor,
with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Starbuck Pashley and
Ms Bakewell have no declared affiliations that could be
perceived as posing potential conflicts of interest in the
publication of this article.
1. Define evidence-based practice (EBP).

2. Identify how EBP affects health care.
3. Discuss how nursing personnel can implement EBP.

article.
Disclaimer
Accreditation
AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses
Credentialing Center approves or endorses products mentioned
in the activity.
106 j AORN Journal
January 2015 Vol 101 No 1
AORN, Inc, 2015
Back to Basics: Implementing

Evidence-Based Practice
2.2
www.aorn.org/CE
ABSTRACT
As health care transitions from volume-based care to value-based care, it is
imperative that perioperative nurses implement evidence-based practices that support effective care. Implementing evidence-based practice is a challenge but improves patient outcomes, standardizes care, and decreases patient care costs.
Understanding how care interventions work and how to implement them is important to compete in todays health care market. This Back to Basics article discusses how to identify, review, and appraise research; make recommendations to
implement new practices; evaluate the outcomes of the implementations; and make
necessary changes to facilitate evidence-based practice. AORN J 101 (January 2015)
107-112. AORN, Inc, 2015. http://dx.doi.org/10.1016/j.aorn.2014.08.009
Key words: evidence-based practice, EBP, perioperative nursing, volume-based
care, value-based care.
ealth care is changing rapidly. Over the

next few years, the transformation from
volume-based to value-based health care
will be significant. Health care alliances, mergers,
and acquisitions are forming and facilities are joining
forces to become major value-driven providers of
health care. Facilities will have to transform care
based on cost-effectiveness and evidence that the
care provided is effective. Care cannot continue to
be driven by tradition or provider preference. The
most important factor in providing the best valuedriven care is the implementation of evidencebased practice (EBP).
Evidence-based practice has existed for decades,
and yet its routine use in the perioperative setting is
lacking. Evidence-based practice combines the best
available research with clinician experience and
patient preference. Health care can be transformed
at the bedside, one patient encounter at a time.1

Without EBP, clinicians do not know whether their
practices provide better outcomes or are cost-effective.2 Another reason that practice in the perioperative setting is changing rapidly is the pace at which
technologies evolve, and EBP enables perioperative
professionals to look not only at which technologies
work but also at what is most cost-effective.
Perioperative professionals are accountable
for the care they give. Because research does not
always get translated into practice, nurses may not
know about evidence-based care and must actively
search for it. In addition, nurses must be able to
critically assess patients and the care provided,
research and appraise the available evidence, and
determine if and how the evidence can be applied
to their practice.2 Evidence-based practice skills
assist perioperative team members who may have
AORN, Inc, 2015
January 2015
Vol 101
No 1
AORN Journal j 107
to justify why they practice a certain way by providing the rationale for their care. For example, if
a surgeon does not want to cover his hair with a
bouffant cap and asks the nurse to explain why, the
nurse can reply Because that is what our policy
says. Or the nurse can explain that there are several
research articles demonstrating that hair can harbor
bacteria that can be dispersed into the air when shed
and that completely covering hair on the head and
facial hair protects the patient from exposure to
potentially pathogenic microorganisms that can
cause surgical site infection. Providing the rationale
is far more likely to result in compliance with the
request than citing a policy that may be interpreted
by personnel as arbitrary.
Evidence-based practice also allows perioperative nurses to explain to patients the significance
of certain care instructions, which helps engage
patients in their care. Consider this example: a patient
is undergoing surgery for a fractured arm and is instructed to elevate the arm to prevent swelling. The
patient does not want to elevate her arm because it
is a difficult position to maintain and questions the
nurse as to why this must be done. The nurse could
say That is what your doctor has ordered. Or the
nurse could explain that raising the arm reduces
swelling that can occur when the arm is positioned
lower than the level of the heart (ie, the rationale
for elevating the arm), which could slow blood
flow (ie, using terminology that is easy to understand without using terms such as compromise or dependent edema). 2 This example shows
how EBP can be used at the bedside with every
patient and individualized based on the patients needs.
Evidence for patient care can be found in many
places. Published literature is the best source, but
there are EBP guidelines from professional organizations (eg, AORN Perioperative Standards and
Recommended Practices3) that have reviewed the
available evidence to produce guidelines appropriate for implementation. Other sources for EBP
are case studies, published clinician experiences,
and data that can be found in the facilitys electronic
108 j AORN Journal
SPRUCE
medical record or by performing a literature
search.
HOW-TO GUIDE
To implement EBP for any clinical practice, perioperative nurses should take the following steps.
Form a project team and identify the scope of
the project. Identify team members, leaders,
change agents, and any other specified team members. It is important to achieve buy-in from all
disciplines involved in the project. The EBP team
should agree on the scope, aim, and objectives
before beginning the project.
Identify the evidence. This can be done individually or with a team of nurses who are interested
in translating research into practice. Learning how
to navigate available databases can be a challenge,
and enlisting the help of a research librarian can be
a valuable resource.4
Conduct a rapid review. Abstracts can provide
a rapid summary of an articles evidence, and
nurses can use abstracts to determine which articles
are relevant to their topic or patient care issue. If
working with a team, team members should work
out a schedule for meetings and dividing the work
among team members who are available during the
identified work hours.4
Assign articles. Team members can conduct a
critical appraisal of each assigned article and can
focus on the quality of the articles by asking the
questions listed in Figure 1.
Use appraisal tools. Using appraisal tools such
as the ones used by AORN can be a great resource
for evidence appraisal (Supplemental Figures 1
and 2). Performing appraisal is important because
the evidence should be from credible sources and
peer-reviewed publications. AORNs tool for
rating appraised articles is presented in Figure 2.
Make practice recommendations. Identify
best practices; based on the evidence, the team
can determine which recommendations are best
BACK TO BASICS: IMPLEMENTING EBP
www.aornjournal.org
Figure 1. AORNs tool for appraising evidence. Reprinted with permission. Copyright 2014, AORN, Inc. All
rights reserved.
for the practice setting and implement those that

are needed.5
Identify implementation strategies. Goode
and Harley5 implemented a successful EBP project
to integrate care pathway for patients undergoing
elective colorectal surgery. These researchers
offered the following suggestions when undertaking and implementing EBP projects:
n
Outline the main steps of the project and gain

institutional review board approval if needed.
Identify areas affected such as the preoperative,
intraoperative, and postoperative areas.
n Plan teaching sessions for team members who
are affected by the project. Identify and create
teaching materials by using presentations or
hands-on teaching methods. Plan additional
individual instruction as needed.
n Conduct a pilot test and provide support to team
members on a daily basis to help them see
change in a positive light; providing support
will help to overcome negative feelings.
n Provide feedback forms to team members, and
encourage feedback throughout the pilot-testing
process.
Make needed changes based on feedback. The

success of any project depends on early preparation and planning and being open to changes
during the pilot testing.
n Conduct additional pilot tests if needed.
n Implement the EBP project across applicable areas.
n Review the process every two years or as needed
when evidence changes or practice needs change.
The Agency for Healthcare Research and Quality offers these strategies to implement EBP1:
n
n
n
n
Choose a change champion who can identify

potential problems and challenges during
implementation.
Test the EBP project in one area before applying
it to other areas.
Use multidisciplinary teams for implementing
the practical aspects of the project.
Use EBP publications (eg, AORNs Guidelines
for Perioperative Practice3) that have already
reviewed the EBP recommendations and offer
useful tools for point-of-care use.
Use technology to integrate EBP in electronic
health records (eg, computerized decision support and prompts in clinical care).
AORN Journal j 109
SPRUCE
Figure 2. AORNs tool for rating articles. Reprinted with permission. Copyright 2014, AORN, Inc, 2170 S. Parker
Road, Suite 400, Denver, CO 80231. All rights reserved.
Provide education as needed to change practice.

n Implement interactive education (eg, simulation, online education modules) along with
other implementation strategies to better promote EBP changes.
n Use change champions and opinion leaders to
promote EBP and changes in current practice.
n Monitor outcomes of the change and communicate them to the entire perioperative team.
BENEFITS
Evidence-based practice benefits everyone in health
care. Facilities that implement EBP are standardizing care for patients based on what has been
shown to yield the best outcome. Evidence-based
practice provides the value in value-based health
110 j AORN Journal
care. Patient outcomes and core measures improve

when care providers follow EBP. Evidence-based
practice is more cost-effective, which is important
for facility and provider reimbursement.
Patients benefit knowing they are receiving care
based on what works best rather than historical
precedence. As a result, patients will be more informed health care consumers because they will
understand what works and what does not, and
then be able to base their treatment decisions
on knowledge rather than on what their provider tells them to do.
Health care providers are accountable for the
care they give, and reimbursement is tied to their
performance. Practicing evidence-based medicine
and nursing gives providers confidence that they
www.aornjournal.org
Figure 3. Advancing Research and Clinical Practice Through Close Collaboration (ARCC) model. Reprinted with
permission from Bernadette Mazurek Melnyk, PhD, RN, CPNP/PMHNP, FAANP, FNAP, FAAN, and Ellen FineoutOverholt, PhD, RN, FNAP, FAAN.
are providing the best health care possible to

their patients.
bedside care team members. To achieve culture

change, these researchers6 recommend having
STRATEGIES FOR SUCCESS

A study of an EBP nurse mentorship program
performed by Wallen et al6 showed clear benefits.
The program helped to improve nurses perceptions
that the facility provided a patient safety culture (an
example of a safe culture assessment tool can be
accessed at http://www.ahrq.gov/professionals/
quality-patient-safety/patientsafetyculture/hospital/
index.html), improved implementation of EBP,
increased job satisfaction, and helped improve
nurse retention. These researchers have developed
a model to guide implementation of EBP on a
system-wide basis (Figure 3).6
Facility personnel should assess their culture for
EBP, identify barriers with a plan to overcome
them, and enlist mentors to work directly with
n
n
n
n
leaders who support an EBP culture along with

a shared governance model;
the resources available to support the EBP process;
initiatives that include administrators, not just
clinicians;
evidence-based practice mentors (eg, nurse
leaders, nurse managers, clinical nurse specialists, nurses with doctoral degrees) who are
knowledgeable about the EBP process, willing
to mentor bedside clinicians, and able to lead
EBP projects;
workshops to develop EBP skills and assist
nurses in becoming EBP champions to promote
and sustain the process; and
continuing support of mentors (eg, celebrations
of successful projects, educational activities.
AORN Journal j 111
SPRUCE
WRAP-UP
As health care continues its progression toward
value-based practice, it is imperative for nurses to
implement EBP to drive improvement in patient
outcomes and increase reimbursement to facilities
and providers. Although change, including implementing EBP, is difficult, this Back to Basics
article addresses some strategies to implement and
sustain EBP.
Patient care must be standardized based on
what yields the best outcomes and what is costeffective; facilities that fail to provide evidencebased care will not survive in this new climate.
The health care system cannot continue to allow
individual practitioners to determine practice the
way they always have. Practitioners must prove
that what they are doing truly improves patient
outcomes and improves the health of perioperative patients.
SUPPLEMENTARY DATA
The supplementary figures associated with this
article can be found in the online version at http://
dx.doi.org/10.1016/j.aorn.2014.08.009.
References
1. Titler M. The evidence for evidence-based practice
implementation. In: RG Hughes, ed. Patient Safety and
Quality: An Evidence-Based Handbook for Nurses.
Agency for Healthcare Research and Quality. Rockville
MD: Agency for Healthcare Research and Quality; 2008.
2. Tame S. The importance of evidence-based practice in
healthcare. Technic J Oper Depart Pract. 2013;4(4):6-9.
3. Guidelines for Perioperative Practice. Denver, CO:
AORN, Inc; 2015.
4. Mong A, Pugh LC. Using evidence-based practice in the
OR: one nurses experience. OR Nurse J. 2013;7(6):12-16.
OR Nurse 2014, http://journals.lww.com/ornursejournal/
Citation/2013/11000/Using_evidence_based_practice_in_
the_OR__One.3.aspx. Accessed October 17, 2014.
5. Goode C, Harley J. Development of an integrated care
pathway for elective colorectal surgery. Gastrointest Nurs.
2009;7(6):38-44. Internurse.com. https://www.internurse
.com/cgi-bin/go.pl/library/abstract.html?uid43347.
Accessed October 17, 2014.
6. Wallen GR, Mitchell SA, Melnyk B, et al. Implementing
evidence-based practice: effectiveness of a structured
multifaceted mentorship programme. J Adv Nurs. 2010;
66(12):2761-2771.
Lisa Spruce, DNP, RN, ACNS, ACNP, ANP,

CNOR, is the director, evidence-based perioperative practice, AORN, Inc, Denver, CO. Dr
Spruce has no declared affiliation that could
be perceived as posing a potential conflict of
Check back in March 2015 for the next Back to Basics topic: Procedural Sedation.
112 j AORN Journal

www.aornjournal.org
114.e1
Supplemental Figure 1. AORNs tool for evaluating non-research articles. Reprinted with permission. Copyright 2014, AORN, Inc, 2170 S. Parker Road,
Suite 400, Denver, CO 80231. All rights reserved.
114.e2
SPRUCE
Supplemental Figure 1. (continued).

www.aornjournal.org
114.e3
Supplemental Figure 2. AORNs tool for evaluating research articles. Reprinted with permission. Copyright 2014, AORN, Inc, 2170 S. Parker Road, Suite
400, Denver, CO 80231. All rights reserved.
114.e4
SPRUCE
Supplemental Figure 2. (continued).
Nursing Shortages in the OR:

Solutions for New Models of
Education
KAY BALL, PhD, RN, CNOR, FAAN; DONNA DOYLE, MS, RN, CNOR, NE-BC;
NICHOLE I. OOCUMMA, BSDH, MA, CHES, CHSE
ABSTRACT
The professional literature predicts worldwide perioperative nursing shortages.
Compounding this is the absence of perioperative curricula in most nursing programs,
which reduces new graduate interest in and awareness of employment opportunities
in the OR environment. Educators at a university and a large hospital system formed
an innovative partnership to create a pilot undergraduate nursing course to better
prepare nurses for the surgical setting. The course was offered in a condensedsemester format and included online activities, simulation experiences, classroom
discussions, and clinical experiences in a small group setting. Two of the four nursing
students in the course were hired directly into the perioperative setting after graduation, decreasing hospital costs related to recruitment and orientation. The success of
the course led to its integration into the undergraduate curriculum, thus providing
a valuable elective option for junior and senior nursing students, as well as
achieving a new model for perioperative nursing education. AORN J 101 (January
2015) 115-136. AORN, Inc, 2015. http://dx.doi.org/10.1016/j.aorn.2014.03.015
Key words: bachelor of science in nursing students, BSN students, BSN curriculum,
perioperative nursing students, simulated learning, perioperative skills, nursing
shortage.
here is a critical shortage of perioperative

nurses,1-5 and the demand for perioperative
nurses in the United States is growing steadily
by 1% to 2% each year.4,6-8 Only a small percentage
of all nurses practice in the perioperative arena, and
it is estimated that nearly 20% of those currently
employed in this specialty area will retire in the
next five years.4 As a result, many health care
environments are beginning to experience the
effects of this long-anticipated perioperative
nursing shortage.4
The shortages in perioperative nursing can be

summarized as the result of many trends that
are intensifying in the workplace today. These
include
n decreased exposure to perioperative nursing
in both the classroom setting and the clinical
environment,1,4
n a perioperative workforce that is aging and
nearing retirement,9
n a patient population that requires more intense
nursing care and complex interventions,1,4 and
AORN, Inc, 2015
January 2015
Vol 101
No 1
AORN Journal j 115

n
technological advancements that require intense

education and skill adaptations.1,4
EFFECTS OF CLINICAL NURSING

EDUCATION
Surgical nursing requires specialized training and
skills that are not routinely offered as part of the
curricula in most nursing schools. Instead, the
extent of many nursing students exposure to
perioperative nursing is limited to the occasional
observation assignment, which prevents them from
comprehending the role of circulating, scrubbing,
or first assisting during surgical procedures. This
creates a knowledge gap in clinical nursing education. As a result, nurse graduates are not aware of
the full scope of the perioperative specialty and
therefore do not apply for perioperative positions.
The limited number of nursing school faculty
members with perioperative experience also contributes to the lack of perioperative nursing education in academia. In addition, even nurses who
have been in practice for several years often are
unaware of what perioperative nursing practice
entails as a result of the limited exposure to perioperative practices.
Many OR managers have encouraged new nurse
graduates interested in working in the OR to gain
one to two years of medical-surgical unit experience before applying for a position in the surgical
environment (D. Doyle, MS, RN, CNOR, NE-BC,
administrative director of surgery and anesthesia,
Grant Medical Center, Columbus, Ohio; in-person
communication; December 12, 2013). The rationale
for recommending medical-surgical experience is
that it helps the novice nurse develop critical thinking
skills. However, as the new nurse becomes part of
the culture on the medical-surgical unit, the probability of transfer to the OR decreases, thus contributing to the already existing perioperative nursing
shortage. When nurses lack perioperative knowledge
and skills and have limited exposure to this environment, even after gaining medical-surgical unit
experience, they can be uninterested in practicing
perioperative nursing. Furthermore, if these nurses
116 j AORN Journal
BALLeDOYLEeOOCUMMA
are hired into the OR, they may have unrealistic
expectations that can lead to dissatisfaction and
disappointment about the perioperative nurses role
and the reality of perioperative nursing.10
Another factor to consider is that nurses with no
previous exposure to perioperative nursing may
decide to quit midway through an intensive orientation program. This in turn creates a financial
burden on the health care facility because orienting
a nurse to the perioperative environment can cost
upward from $59,000 (D. Doyle, MS, RN, CNOR,
NE-BC; in-person communication; December 12,
2013).4 Thus, nurses who quit during an orientation
program can be a tremendous loss for a facility, not
only in dollars but also in human resources (as
discussed more in depth later in this article).
Results from a survey of OR leaders, which was
conducted at a 2012 perioperative nurse leader conference, confirmed the potential for a future shortage
of perioperative nurse leaders.5 Respondents (73.4%)
reported that they are current OR nurses who are
older than 50 years of age, 76% of respondents reported 20 or more years of nursing experience, and
approximately 65% of respondents reported that they
plan to retire in 10 years or less. These results suggest that the anticipated demand for nurse leaders
aligns with other nursing research related to the
perioperative nursing shortage.1,4,6,7,9
Changes in curricula standards for nursing education amplify concerns about the perioperative
nursing shortage.1,11,12 Because programs for an
associate degree in nursing (ADN) and a bachelor
of science in nursing (BSN) contain vast amounts
of professional and clinical information, educational institutions offer fewer courses in clinical
specialty areas.9 Rotations for clinical observation
experiences in the perioperative environment have
been eliminated from many BSN programs, and in
most cases, undergraduate nursing students are not
exposed to perioperative nursing at all during their
clinical or practicum experiences.1,4,9,11 Many individuals being oriented into specialty nursing
practice are recent graduates, and hospital administrators experience difficulty successfully filling
RESPONDING TO THE OR NURSING SHORTAGE
www.aornjournal.org
perioperative nursing positions if nursing student

candidates were not introduced to surgical environments during their schooling.1,6 Researchers
have noted that school exposure to perioperative
nursing influences whether nurses choose the OR
as their area of practice.3,9
experience required to help them transition from

student to professional nurse and to establish them
as productive members of the surgical team.1,4,6,7,11
Historically, only half the perioperative nursing
workforce remains in a surgical setting for longer
than two to three years because of the need for
extensive orientation and professional development.7 These estimated data do not take into acECONOMICS OF THE NURSING
count the effects of turnover common to all nursing
SHORTAGE
specialty areas, such as stress on the remaining
Surgery departments are often referred to as the
workforce and lack of patient care continuity.
economic engines of health care facilities because
The challenges and barriers for training,
they can generate as much as 60% of a hospitals
13
recruiting, hiring, and retaining qualified perioprevenue. Perioperative nurses have reported that
erative nurses are numerous. Solutions to reduce or
surgical volumes have continued to increase from
14
5
meet these challenges are critical to maintaining a
14% in 2009, and Sherman et al note that a
perioperative workforce that can meet projected
recent nationwide survey reports that surgical voldemands. For example, aggressive recruiting is being
umes have increased in 2012. Because baby boomers
used to attract nurses
are living longer and
to fill perioperative
experiencing more
nursing positions.
complex health isHealth care facilities and nursing schools are
Creative recruitment
sues, surgical volforming collaborative partnerships to revise
strategies include signumes are predicted to nursing education models by introducing
on and bonus incencontinue their steady
detailed perioperative nursing courses with
5
tives. However, hiring
increase. This preclinical experiences into the already packed
interested nurses into
cipitates an increased nursing curricula.
roles that they may not
demand for periopfully understand to
erative nurses and an
address capacity issues may have an adverse effect
even greater demand for nurse leaders in the sur5
on safe patient care, which is the ultimate goal of
gical specialty practice. Succession planning does
perioperative nursing. Other trends in recruiting
not appear to be a priority for OR directors and
include traveling nurse companies that are recruitmanagers (eg, lack of planning strategies and
ing more and more nurses to fill vacant perioperaadministrative support, no expectation that nurse
tive roles as a result of hospitals that are shifting
leaders participate in this planning), and this results
nurses from other similar positions, such as in
in a universal need to strategize about how to fill
gastrointestinal laboratories or obstetrics units, to
this predicted void.5
work in the OR. Some facilities are conducting
The cost of recruiting, hiring, and orienting
tours and educational programs for existing nurses
nurses to a specialty area is difficult to calculate.
to pique their interest and to urge them to enter the
According to the literature, the cost to orient a
field of perioperative nursing. Finally, health care
nurse to the OR is estimated to start at $59,000, but
facilities and nursing schools are forming collabcan rise well above that amount when including the
orative partnerships to revise nursing education
cost of the application process, recruitment, and
models by introducing detailed perioperative
interviewing and hiring processes.1,4,6,7,11 Addinursing courses with clinical experiences into the
tional costs associated with hiring new nurse
already packed nursing curricula.9
graduates include the extensive time and practical
AORN Journal j 117
BALLeDOYLEeOOCUMMA
CREATING A PERIOPERATIVE NURSING

PROGRAM
In 2012, the director of surgery at a Midwestern
hospital system attended a presentation at the
annual AORN Congress about the recruitment of
nursing students into the perioperative specialty
through a partnership with an academic nursing
program. In response to this presentation, this director of surgery recognized the need to create a
pool of potential perioperative nurses to fill staffing
needs and saw an opportunity to address the growing
perioperative nursing shortage in her hospital system. She approached the dean of nursing at a local
university and suggested a partnership between
her hospital system and the university to pilot a
simulation-based elective course to increase interest, knowledge, and skills in perioperative nursing
among senior students. The dean then contacted
one of the university faculty members who is a
perioperative nurse to lead this initiative.
A partnership between the hospital system and
university had previously existed with the creation
of a nurse anesthesia program. That program was
so successful that faculty at the university expected
a partnership for the proposed perioperative nursing
course to be a resounding success. The university
involved in this partnership is located in a residential community of approximately 36,000 residents and is highly acclaimed, ranking 14th among
146 peers in the UniversitieseMasters (Midwest)
category of the 2012 edition of Americas Best
Colleges by U.S. News & World Report.15 Annual
student enrollment at the university is more than
3,000 students, who have a choice of 73 majors and
44 minors along with individualized courses of
study. The university offers programs for students
to earn bachelors, masters, and doctoral degrees
in nursing. Approximately 60 to 70 students graduate each year from the undergraduate program
for nursing.
The hospital system is a not-for-profit charitable
health care organization that Fortune magazine has
recognized as one of the 100 Best Companies to
Work For.16 As one of the top five largest health
118 j AORN Journal
systems in America, it comprises a network of 11

hospitals, more than 50 ambulatory sites, hospice
and home-health services, medical equipment
supply, and other health services that span a diverse
rural, urban, suburban, and Appalachian 40-county
area across the state.16,17 With more than 22,000
employees, this hospital system has several facilities that range in size from 100 beds to more than
1,000 beds. Each hospital and several satellite care
sites in this system offer surgical services in their
facilities.
Determining the Stakeholders
Administrators at both facilities approved the
partnership between the university and the hospital
system. The first step of this collaborative effort
involved determining the stakeholders who would
be directly involved with the creation of the course.
The OR director and the university perioperative
faculty member chose staff members to join them
at the planning table. Selected staff members included four perioperative educators from three of
the hospital facilities, one OR manager, and one
simulation laboratory expert. Although there was
only one faculty member at the university with
perioperative experience, other faculty members
volunteered to help with the course as needed.
These initial stakeholders determined the major
steps in the process of creating and conducting
the perioperative educational experience. These
included
n
establishing the course description and goals,

n developing a curriculum and schedule,
n implementing the course, and
n evaluating the success of the program.
They developed a pilot perioperative elective
course and offered it during a condensed semester,
referred to as a J-term because it was held in
January 2013. The J-term consisted of an intensive three-week learning experience that offered
three credit hours, which is the same number of
credit hours offered by courses that are conducted
during a full semester.

Although the collaborative relationship among
these specific stakeholders was new to all, they
formed an immediate bond. The success of this
close partnership would demonstrate the need, opportunity, and quality of future cross-disciplinary
joint ventures for both the university and the hospital system. The planning committee hoped that
the pilot course would increase academic opportunities in specialty nursing courses offered by the
university and that it would help address staffing
needs within the hospital. For example, the success
of this collaborative partnership could not only
ensure future staffing for the ORs, but also serve as
a model to provide staffing and reduce orientation
time for other specialty nursing areas.
Planning Meeting Initiatives
The university faculty member created a description of the perioperative course to market it to
senior nursing students. Included in the course
description was the following statement:
This perioperative nursing course will introduce
perioperative nursing, including aseptic technique principles, equipment used in the OR,
perioperative patient care considerations, and
other critical surgical topics. A strong foundation of perioperative knowledge and skills will
be provided in classroom, simulation, Internet,
and clinical experiences. At the end of this
course, the student will realize if perioperative
nursing is a specialty area that is attractive to
the student for future employment.
The planning team reviewed the course description
and determined the following goals for this collaborative effort:
n
Integrate experiential learning and simulation

into the learning/training environment for perioperative nursing students.
n Develop a course that enhances the recruitment
of nurses into the perioperative environment.
An anticipated indirect outcome of this course was
to shorten the overall OR orientation process for
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newly hired graduate nurses who participated in

this perioperative elective.
The university faculty member also introduced
a comprehensive list of course objectives for the
planning team to review. The six course objectives
(Table 1) aligned with the nursing accreditation
standards (ie, Essentials)18 and AORN perioperative standards19 and established a framework to
direct lecture, simulation, and clinical experiences.
After review and approval of the course description
and objectives, the next detail for committee
members to address was determining teaching
methodology for the course.
Teaching Methodology
Traditional approaches to nursing education, including classroom lectures, laboratory return demonstrations, and basic memorization, often lead to
technical mastery but may not promote critical
thinking.20 Because critical thinking acquisition is
related to structured practice, the design of teaching
and learning strategies needs to promote active
rather than passive learning. According to Kolb,21
learning is a continuous process, and the way a
person thinks and behaves can be changed by
imprinting experiences into existing intellectual
frameworks. Although Kolbs theory is not recognized as a specific nursing theory, it can be used
as a firm foundation for the creation and implementation of a perioperative nursing course.
Research shows that undergraduate nursing
curricula should prepare students in the skills
required to function effectively on medical teams.22
Therefore, members of the committee chose a
collaborative, experiential, group learning environment to present a valuable teaching atmosphere
and enhance the learning of perioperative knowledge and skills. Committee members hoped that
this type of learning environment would increase
the students understanding of group processes,
roles, communication skills, and self-awareness
in a manner conducive to professional growth.
Because teamwork is the foundation of perioperative practice, students exposure to collaborative
AORN Journal j 119
BALLeDOYLEeOOCUMMA
TABLE 1. Perioperative Course Objectives and Essentials

Course objective with nursing essential
Topics
1. Identify leadership skills needed to promote a safe perioperative environment and high-quality surgical care
(Essential II: Basic Organizational and Systems Leadership
for Quality Care and Patient Safety)1
2. Describe current evidence and best practices that provide
the foundation for perioperative nursing practice (Essential
III: Scholarship for Evidence-Based Practice)1
3. Explain patient care technology (eg, surgical devices,
equipment) needed during surgical procedures to maximize
clinical outcomes (Essential IV: Information Management
and Application of Patient Care Technology)1
4. Discuss the importance of meaningful communication and
active collaboration among the different surgical team
members to enhance high-quality and safe perioperative
patient care (Essential VI: Interprofessional Communication
and Collaboration for Improving Patient Health Outcomes)1
5. Exhibit the ethical and caring attributes of having a surgical
conscience when functioning in the perioperative environment (Essential VIII: Professionalism and Professional
Values)1
6. Assess the complexity and variations in the physical and
behavioral responses of patients and their families or signicant others to the surgical experience (Essential IX:
Baccalaureate Generalist Nursing Practice)1
Control measures to enforce proper attire and trafc patterns

within different perioperative zones, patient safety practices
for quality surgical care, hazards in the OR, emergencies in
the OR
Infection prevention practices, use of the Perioperative
Nursing Data Set,2 anesthesia options
Energy devices used in surgery, instrumentation, sterilization
equipment, positioning devices, airway management
technology
Different roles and responsibilities of perioperative team
members, the art of communication in a stressful environment, effects of active collaborative activities
Clinical experiences in different areas of the perioperative

environment, professionalism, ethics
Preoperative assessment, distinguishing perioperative care

involved with different age groups, involvement of family
members or signicant others before, during, and after the
surgical experience
1. American Association of Colleges of Nursing. The Essentials of Baccalaureate Education for Professional Nursing Practice. Washington, DC: American
Association of Colleges of Nursing; 2008.
2. Petersen C. Perioperative Nursing Data Set. 3rd ed. Denver, CO: AORN, Inc; 2011.
learning environments in the classroom and skills

laboratories is critical to becoming effective team
players in their nursing careers.
Critical thinking. Critical thinking is a core skill
in perioperative nursing and can be practiced
through the use of simulation and the application of
adult learning theory.23 Simulation experiences can
help novice students understand specific patient
care situations that may change the manner in
which nursing care is delivered. The student can
feel an increased sense of self-efficacy and confidence in the clinical practice setting when simulation experiences are provided.22,24,25 Being able
to apply learning and theoretical principles in a
simulation setting has been demonstrated to improve communication, confidence, and clinical
120 j AORN Journal
judgment25,26 and enhance performance.24 By

providing simulation opportunities in nursing
education, students are able to practice skills and
apply nursing care theoretical principles in a safe
environment.24,25 Advances in technology during
the past decade have generated opportunities to
create realistic simulations during which nursing
students can develop and demonstrate skills and
clinical judgment without endangering real patients.1
Simulation. Although ultimate clinical proficiency was not an objective of this course, planning
team members agreed that simulated clinical experiences provide nursing students with the link
between nursing theory and practice. Through
simulated learning activities, nursing students can
provide safe care even if they are novices.25 These

simulated experiences that demonstrate specific
perioperative skills, which are often missing in the
traditional clinical skills laboratory setting, were
deemed a requirement for this nursing specialty.
Nursing courses that integrate simulation with
didactic learning contribute to improved selfefficacy and confidence levels25 and may be identified as an early factor in whether nurse students
will go on to select perioperative nursing as a
career focus. The planning team agreed that experiential learning in the simulation laboratory, which
considers reflection and conceptualization during
practice, would serve as a framework for the course,
thus allowing a focus on hands-on simulation
experiences to increase student engagement and
learning retention.
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in simulation classes. These modules would be

used to enhance the students knowledge of the
perioperative skills that they would practice during
their simulation experiences. Reviewing these
modules before the simulation experience would
help students feel more comfortable with the skill
expectations. Included module topics were
n
n
n
n
n
n
n
n
anesthesia;
perioperative assessment;
scrubbing, gowning, and gloving;
positioning the surgical patient;
safety in the surgical suite,
skin prep;
surgical instruments; and
sterilization and disinfection.27
The planning team chose these specific modules

Collaborative Curriculum
because they could be coupled with the simulation
During six planning meetings, members of the
experiences and be used as the main instructional
committee created a skeleton perioperative currictools. Faculty alternated among online, didactic,
ulum. They began development of the curriculum
simulation, and clinical learning experiences over
by discussing current
the three-week J-term
and best practices,
to provide a comprefacility options, and
hensive educational
Nursing courses that integrate simulation with
technology capabilexperience.
didactic learning contribute to improved selfefficacy and confidence levels, and may be
ities. The program
The university asidentified
as
an
early
factor
in
whether
nursing
planners needed to
signed three credit
students
will
go
on
to
select
perioperative
align their attitudes
hours to the course. At
nursing as a career focus.
and ideas about the
the university, credit
course before they
hours are measured as
could develop a colfollows: 14 hours of
laborative curriculum. University faculty and OR
learning (ie, didactic) is worth one credit hour,
educators toured the simulation centers to observe
with one hour equal to 60 minutes; courses worth
the training technology and facility capabilities.
three credit hours must reflect a course schedule
This aspect of planning the simulation segment of
with 42 hours of learning time. At this university,
the course was critical because students would
four clinical hours are equal to one didactic hour (ie, a
need creative simulation scenarios to develop
4:1 ratio) so the students were assigned to five days
actual perioperative skills.
(40 actual hours) in the clinical environment (with
The planning team also explored how to best
one day being a tour of the perioperative facilities),
prepare the students for the simulation experiences.
which equates to 10 didactic hours. Table 2 illustrates
After reviewing and discussing different learning
the final schedule, with an outline of the various
opportunities, members of the planning team selearning methodologies and assignments integrated
27
lected eight AORN Periop 101 training modinto the course curriculum and the number of didactic
and clinical hours for each session.
ules for the students to review before participating
AORN Journal j 121
Date/day/time
January 3
Thursday
7 AMe3:30 PM
Class 1: Simulation
January 4
Friday
7 AMe3:30 PM
January 7
Monday
7 AMe3:30 PM
January 8
Tuesday
7 AMe3:30 PM
January 9
Wednesday
7 AMe3:30 PM
January 10
Thursday
January 11
Friday
7 AMe3:30 PM
January 14
Monday
7 AMe1:30 PM
January 15
Tuesday
7 AMe3:30 PM
January 16
Wednesday
7 AMe3:30 PM
January 17
Thursday
7 AMe3:30 PM
Clinical: Groups 1 and 2 tour hospitals, including simulation

laboratories and the perioperative environment
Class 2: Simulation
Clinical, day 1: Group 1 (8 clinical hr)
6
7
10
11
Assignments/continuing education credit

Periop 101
n Anesthesia (1.3 CE)
n Perioperative assessment (2.0 CE)
n Scrubbing, gowning, and gloving(1.0 CE)
Skin Preps (1.5 CE)
Positioning the Surgical Patient (2.5 CE)
Safety in the Surgical Suite (3.0 CE)
(Snow day backup)

Class 3: Simulation
Surgical Instruments (2.0 CE)

Sterilization and Disinfection (2.5 CE)
BALLeDOYLEeOOCUMMA
Clinical education (clinical hr)
Didactic hrb
Day
122 j AORN Journal
TABLE 2. Schedule for the Perioperative Nursing Course
Day
Date/day/time
12
January 18
Friday
8 AMe2:30 PM
January 21
Monday
January 22
Tuesday
7 AMe3:30 PM
January 23
Wednesday
7 AMe3:30 PM
January 24
Thursday
8e10:00 AM
January 25
Friday
8e11:00 AM
13
14
15
16
Clinical education (clinical hr)

Class 4: Simulation and student presentations
Didactic hrb
6
Assignments/continuing education credit

Prepare for presentations
Holiday (snow day backup)

Class 5: Review and practice perioperative skills and

reections on perioperative experience by students
Examination (simulation)
Prepare for the nal examination (simulation)
TABLE 2. (continued ) Schedule for the Perioperative Nursing Course
Periop 101 is a registered trademark of AORN, Inc, Denver, CO.

a
b
This three-week elective course was offered during the month of January, also known as the J term.
Total didactic hours 42, which is equivalent to three university credits; four clinical hours one didactic hour.
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AORN Journal j 123
Challenges
Committee members identified and discussed
the challenges of this new perioperative course
at the planning meetings. These challenges
included
n
marketing a new elective course to senior

nursing students who have other options for
their between-semester break,
n J-term time limits and the unpredictability of
weather because the course would be conducted
during a winter month,
n limiting the number of students who could be
accommodated while identifying suitable clinical experiences, and
n creating perioperative preceptor criteria.
J-term. The J-term is an intensive experience for
students that is offered each year during the month
of January, which is strategically placed between
the fall and spring semesters. As an optional enrollment opportunity, many innovative electives
that the university offered during J-term (eg, study
abroad, service-type courses) could be seen as
competition for the new course. The planning team
knew that marketing of the new course and J-term
time and enrollment limits could make it difficult
to attract students. Additionally, participating in a
J-term course reduces time off between semesters
from six to two weeks. Students often use this time
off to work, travel home, or take vacations, and
it represents the last academic break for senior
students. Intense marketing for the perioperative
J-term course to address these challenges included
describing the details and benefits of this exciting
new course at some of the fall senior nursing
classes, conducting individual meetings with
students by the perioperative faculty member to
determine interest, and answering e-mail questions
posed by potential students. The passion displayed
by the faculty member for perioperative nursing
was evident to the students and created an enthusiasm
for this course that was demonstrated when it immediately filled to capacity.
124 j AORN Journal
BALLeDOYLEeOOCUMMA
Weather. The next challenge involved the unpredictability of weather during the month of
January in this midwestern state. Any course
offered during the winter has the potential for being
adversely affected by the weather. Even though
the course schedule was very intense to allow it to
be completed in three weeks, the planning team
identified, published, and reserved alternate dates
for students to attend backup classes if any were
missed because of inclement weather. If the university had to close because of weather, the simulation or clinical day also would be cancelled. In
the event of a cancelled class due to inclement
weather, students bore the responsibility of contacting their assigned preceptors so that rescheduling could be accomplished.
Enrollment limits. The planning team spent
considerable time discussing the limitations created
by the number of students who could be accommodated and the clinical experiences they would
have. Hospital-site restrictions for staffing and the
space necessary to accommodate the students were
also considered. Across the United States, student
access to perioperative clinical rotations has been
prevented by the high volume of surgical procedures
being performed, limitations on the number of
professionals allowed to be present during specific
procedures, the need for extra scrub attire to clothe
students, and the number of nurses already being
oriented who have priority for experience in surgical
rooms.1 This course represented the first time that
students were allowed to have a clinical experience
in the OR within this hospital systems campuses.
Therefore, ensuring that personnel in the various
perioperative areas were accepting of the students
was extremely important. The planning team worked
to help ensure that the students had a positive learning
experience, but they also worked hard to see that OR
personnel were supportive of these experiences, saw
them as valuable, and were minimally burdened by
the students presence. The planning team used
education and change management strategies to
discuss student presence in the OR and to identify
Class 1 (8 hr)
7e7:30 AM
Introductions
Class 2 (8 hr)
7e9 AM
Simulation experience with RN

educators, simulation experts,
university faculty
n Scrubbing
n Gowning
n Gloving
Class 3 (8 hr)
7e11:30 AM
Energy presentations and demonstrations

7e7:30 AM
Hazards of surgical smoke (university
faculty)
7e10:30 AM
Electrosurgical and ultrasonic energies
(industry representative)
n Electrosurgery
n Monopolar
n Bipolar
n Advanced bipolar
n Ultrasonic energy
10:30e11:30 AM
Laser energy (industry representative)
7:30e10 AM
Simulation experience, continued

Positions:
Supine
n Prone
n Lateral
n Lithotomy
Positioning devices
n
(table continued)
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AORN Journal j 125
General overview and basic

9e11 AM
information
Presentation by university faculty:
n Overview of course
n Perioperative environment
n Recommended practices and
standards (AORN)
n PNDS, ethics, professionalism
n Terminology
n Where surgery is performed
n Roles in the OR
n Surgical attire
n Zones, trafc patterns
n Patient ow through the OR
n Emergencies in the OR (re safety,
radiation safety, respiratory or cardiac arrest)
n Perioperative assessment
TABLE 3. Detailed Schedule for Perioperative Nursing Course
Class 1 (8 hr)
Class 2 (8 hr)
Simulation laboratory tour and experience with RN educators, simulation

experts, and university faculty
n Zones, trafc patterns, attire
n Surgical setup
n Equipment introduction
n Where different surgical team
members stand or function; role of
team member (role play)
Noone12:30 PM Lunch
11e11:30 AM Lunch
12:30e2:30 PM Simulation experience, continued
11:30 AMe
Simulation experience, continued
n Opening packs and supplies
1:30 PM
Skin preps
n What is sterile, what is not sterile
n Different types of skin preps
n How to move around in a sterile
n Skin prep techniques
environment
n Communication
n Universal ProtocolTM (time out)
n Among surgical team members
n Documentation (eg, operative
records)
Class 3 (8 hr)
10 AMenoon
2:30e3:30 PM
Anesthesia types presentation by

anesthesia professional
11:30e12:30 PM Lunch
12:30e1:30 PM Airway management and assisting
the anesthesia professional
Presentation and simulation experience
(anesthesia professional)
1:30e3:30 PM
Simulation experiences (university faculty, RN educators, simulation experts)

n Laparoscopic mentor
n Laparoscopic box
BALLeDOYLEeOOCUMMA
1:30e3:30 PM Simulation experience, continued

Identifying different instrument groups
and their uses
n Instrument groups
n Instrument uses
Counts
n Sponges
n Instruments
n Needles
126 j AORN Journal
TABLE 3. (continued) Detailed Schedule for Perioperative Nursing Course
Class 4 (6 hr)
8e10 AM
10e10:30 AM
10:30e11 AM
11e11:30 AM
11:30 AMenoon
Noone12:30 PM
12:30e2:30 PM
Simulation laboratory (university faculty,

RN educators, simulation experts)
n Simulation quiz: identify what is
wrong in an OR room (setup,
practices)
n Students individually identify inconsistencies (eg, room setup,
practices)
n Class discussion
Student presentation no. 1
Lunch
Reections on and discussion about
clinical experiences
Class 5 (2 hr)
8e10 AM
Review and practice for simulation

experience nal examination (university faculty, RN educators, simulation
experts)
Class discussion, debrieng
Final Examination (3 hr)

8e11 AM
Simulation laboratory examination

(university faculty, RN educators,
simulation experts)
Role play and skills assessment
n Students individually demonstrate
the roles of the RN circulator and
scrub person
TABLE 3. (continued) Detailed Schedule for Perioperative Nursing Course
The Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery is a trademark of The Joint Commission, Oakbrook Terrace, IL.
PNDS Perioperative Nursing Data Set.
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AORN Journal j 127
the advantages of this new elective in various

meetings with OR personnel and surgeons throughout
the planning phase of the course. The planning committee published articles in the hospital newsletter to
communicate progress of planning for this course
within the department. The committees decision to
maintain a low enrollment, with a maximum of four
students, was to minimize disruption to OR personnel
and enable a smooth transition to a new learning
model.
Preceptor criteria. The inclusion of students
in the perioperative areas for their clinical experiences was new for the hospital system; therefore,
the planning team had to review the academic and
hospital campus preceptor requirements. The university requires that preceptors have an unencumbered professional nursing license (ie, no violations,
no restrictions on practice) and at least two years
of perioperative experience with a demonstrated
competence in this area of clinical practice. Additionally, the OR managers at the hospital campuses
would need to provide these staff member preceptors during the students scheduled clinical days.
The ongoing challenges of nursing shortages in the
OR, the limited number of nurses willing to serve as
preceptors, and the need to provide a consistent
learning experience for the students presented
barriers that had to be addressed before the start
of the course. To address these issues, the course
educators met with each potential preceptor to
discuss the role of the preceptor, student assignments and skills laboratory experiences, and other
expectations to provide a consistent and effective
clinical experience.
IMPLEMENTING THE PILOT COURSE
The university faculty member along with a team
of OR nurse educators and the simulation laboratory expert led the entire curriculum, as outlined in detail in Table 3. A variety of teaching
methods were used during the course, including
lecture, discussion, case studies, group presentations,
Internet assignments, audiovisuals, demonstration,
simulations, observation, and clinical experiences.
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BALLeDOYLEeOOCUMMA
Because each segment of the course was built on
the previous segment (eg, the assignments using the
AORN Periop 101 online modules prepared the
student for the classroom presentations), the classroom presentations reinforced this new information
and allowed students to discuss the material and ask
questions. By the time students entered the simulation laboratory to practice a specific skill, they
had the foundational information to demonstrate
their understanding of the concepts presented in
class. The simulation laboratory also provided a
safe setting for practice without the negative consequences of performing a skill incorrectly in the
clinical setting. The skills could be practiced over
and over until the student felt comfortable and
exhibited competence. Finally, the student entered
the clinical environment to perform the newly
learned perioperative skills in the real setting with
real surgical patients. The students clinical time
also allowed them to expand their knowledge of
perioperative nursing by experiencing the sequences of events during the actual care of a surgical patient, which cannot be learned in the
simulation laboratory.
During the courses first day of class, university
faculty introduced students to various settings in
the perioperative environment and the role of the
perioperative nurse. Perioperative practices are
evidence based; therefore, instructors explained
how to use the AORN Perioperative Standards and
Recommended Practices20 as a valuable resource
and also discussed ethics, professionalism, and
other expectations of a perioperative nurse. Other
topics covered were surgical attire, traffic patterns,
patient flow, responding to emergencies, and perioperative assessment. The students visited the
simulation laboratory to review zones within the
OR and identify routine surgical furniture and
equipment. The hospital educators enacted a simulated exercise portraying the different roles within
the surgical suite, along with how each professional
functions during a procedure. The students were
taught what is sterile and what is not sterile and
how to move within a surgical suite. Later in the
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positioning devices and identified pressure points,

day, the students practiced opening different types
after which the students practiced positioning a
of packs and supplies while demonstrating a sursimulated patient while using padding when necgical conscience. A simulation along with reflecessary. Faculty also demonstrated different skin
tion was held at the end of the day to discuss time
prepping solutions, prepping kits, and techniques.
outs, surgical counts, and documentation principles.
The students were expected to perform an abdomThis first day culminated with a presentation by a
inal prep using two different types of prep kit
nurse anesthetist on general, regional, and local
applications. Instructors reviewed instrument cateanesthesia.
gories, and the students were able to handle and
With this introduction to perioperative nursing,
examine the various instruments in a general surthe next day the students then toured two hospitals
gery set. One of the goals of this activity was to
and visited the different preoperative areas, intraprepare the students for their first day of clinical
operative rooms, postanesthesia care units, and
experience.
sterile processing departments. The students were
For the first clinical day, students were assigned
able to note the different surgical settings, attire to
to one of three surgical sites on two hospital cambe worn, sterile technique, patient communication,
puses. Clinical time
and other basic periwas spent one on one
operative practices.
with a nurse preceptor
Each student was able The preceptors understood what the students
experienced in surgery
to see his or her ashad covered in the classroom and simulation
orientation. The presigned clinical site,
laboratory and were able to build on that
ceptors understood
which helped the stu- knowledge by ensuring that the students were
able
to
perform
some
of
those
skills
under
the
what the students had
dent feel more comdirect supervision of the preceptor.
covered in the classfortable for the first
room and simulation
day of the clinical
laboratory and were
experience.
able to build on that knowledge by ensuring that the
The second class provided intense simulation
students were able to perform some of those skills
experiences to practice the skills of scrubbing,
under the direct supervision of the preceptor. The
gowning, and gloving; patient positioning; patient
clinical experiences offered reinforcement of the
skin preps; and surgical instrumentation. Four edgroup learning activities gained in the classroom
ucators were present, and each student had his or
and simulation laboratory. The students had a total
her own educator to review the simulated skills to
of four clinical days during this J-term course, each
be practiced. This one-on-one relationship fostered
lasting eight hours.
quick learning by the students because immediate
The third classroom/simulation day began with
attention could be given to assist the students and
a presentation about the hazards of surgical smoke
answer questions. The students were able to obby the university faculty member. An industry
serve one other, which gave them a sense of pride
representative then described electrosurgical enand accomplishment when a skill was performed
ergy and gave a general presentation about how
well. The university faculty member was also preelectrical energy is used to cut and coagulate tissue.
sent to answer questions and offer information on
The representative then conducted a skills laborabest practices. After the students learned to scrub,
tory to demonstrate the electrosurgical energy.
gown, and glove, they were expected to gown and
Three students were allowed to practice cutting and
glove one another. Patient positioning included
ablating different substances, including steak,
supine, prone, lateral, and lithotomy positions. Inchicken, and apples, while one student was in
structors demonstrated the proper use of various
AORN Journal j 129
BALLeDOYLEeOOCUMMA
charge of smoke evacuation. An industry representative from a laser company provided information about laser biophysics and safety. The students
again returned to the laboratory to observe the
setup of a carbon dioxide laser and then to practice
using this energy by writing their names on wet
tongue blades. They also compared the action of the
laser beam on the tissue with the electrosurgical
energy. Instructors discussed other energies used in
surgery, including ultrasonic and thermal (heat and
cryotherapy) energies. Next, the director of the
nurse anesthetist program along with a senior student nurse anesthetist presented a session about
airway maintenance and discussed how the perioperative nurse can best assist an anesthesia professional during induction. The students were then
shown the basics of intubation and were allowed to
try to intubate a simulation manikin to help understand how to best help an anesthesia professional during intubation. At the end of the class, the
students were able to use a laparoscopic simulator
while trying to perform a laparoscopic cholecystectomy. The students quickly realized the difficulty maneuvering instruments during laparoscopic
simulation.
During the J-term, the students were able to use
their perioperative knowledge and skills in the
surgical setting. The preceptors managed the students as they circulated and scrubbed for a variety
of different procedures. During the last week of the
course, the students took the final examination,
which was simulated. The four educators set up a
surgical scene portraying the roles of circulating
nurse, scrub nurse, surgeon, and anesthesia professional, with a simulator manikin as the patient.
The students were instructed to write down every
infraction noted (eg, attire, sterile technique,
sterile environment, communication) and were expected to find at least 15 errors during this scenario.
Some of the errors included
n
n
hair hanging out of the surgical cap,

uncovered dangling earrings worn by the scrub
nurse,
130 j AORN Journal
n
n
n
n
n
n
n
n
the RN circulator handling bloody sponges with

bare hands,
the anesthesia professional wearing her mask
under her nose,
the patients arm abducted too much,
the patients feet uncovered,
the electrosurgical unit (ESU) pencil dangling
below the sterile field,
no goggles worn by the surgeon,
the count written incorrectly on the white board,
and
a coffee cup on the anesthesia machine.
At the end of the session, after each student had

completed the quiz, instructors held a debriefing
session to discuss each infraction. This experience
not only provided a great learning experience, but
the students stated that they really had fun with this
type of learning.
In the afternoon of the fourth class session, each
student delivered a presentation on a surgical patient he or she followed during a clinical experience. The students were instructed to pick a
patient during one of their clinical days and visit
with the patient preoperatively to learn about the
patients physical, emotional, and mental states and
discuss the surgery to be performed. The student
was expected to accompany the patient into the
surgery suite and assist with the circulating duties.
The student then accompanied the patient to the
postanesthesia care unit area and observed the patients experience in this area until discharge. After
obtaining the patients permission and referring
only to the patient as my patient, the student
prepared and presented the case study to the other
students, educators, OR director, and university
faculty members in the audience. The student also
reflected on this perioperative experience and how
it affected him or her.
The day before the end of the course, faculty
members scheduled a practice time for students in
the simulation laboratory so that they could practice any skills they felt weak in performing. The
four educators assisted the students in performing
www.aornjournal.org
all the skills taught during this course and the skills
next class. The student in the RN circulator role
they would be expected to perform in the final
was expected to perform the following skills:
simulation examination the next day. The students
n open sterile packs and supplies,
practiced all the skills, but seemed to focus on
n greet the patient,
gowning and gloving, along with patient preps,
n identify the patient,
because these tasks seemed to be more difficult
n move the patient onto the surgical bed (with
for the students to perform. After the practice seshelp from others),
sion, the students returned to the classroom to
n position the patient for a procedure,
discuss the final examination expectations with
n apply the ESU pad,
the four educators and the university faculty
n tie up the scrub persons gown,
member.
n remove the scrub persons contaminated glove,
On the last day of the course, the students took
n open another sterile glove for the scrub nurse,
the final simulation examination in the presence of
n participate in the count,
the four educators and the university faculty memn record the count on the white board,
ber. Instructors took two students at a time into the
n pour liquid onto sterile field, and
simulation room and observed as one student
n conduct the time out.
performed the role of
the scrub nurse while
The educators asked
the other served as
The most notable outcome was the increased questions during the
the RN circulator.
examination to test the
interest in perioperative nursing that led to
Then the students
students knowledge
two of the four senior nursing students who
switched roles so
of a particular skill
completed the course being hired by two of
that each student
or practice. After the
the hospital campuses.
had an opportunity
first two students were
to perform in each
finished, the other two
role. In the scrub nurse role, the student was
students experienced the same method of examinaexpected to perform the following skills:
tion. After completion of the final examination, instructors held a debriefing to highlight the experience
n open gown and gloves for donning after the
while answering any questions from the students.
scrub,
The university requires that a student achieve at
n scrub,
least a 77% total average for the coursework. In the
n dry their hands after the scrub,
clinical environment, the student also must achieve
n don a gown and use closed glove technique to
at least a satisfactory rating from the preceptor, on
don gloves,
a scale of outstanding, satisfactory, and unsatisn gown and glove another member of the team,
factory, to pass the course. All students performed
n request a contaminated glove be removed and
well according to their clinical preceptors and
then re-glove,
received A grades for this part of the course.
n participate in a sponge and sharps count,
Each of the three simulation classes was worth 15
n receive liquids onto the sterile field and label
points, the student presentation of a case study was
the liquid,
worth 15 points, the simulated quiz was worth 15
n participate in the time out, and
points, and the final simulation examination was
n remove a contaminated gown and gloves.
worth 25 points, for a total of 100 possible points
for the entire course. The university faculty memStudents were not asked to demonstrate passing
ber, together with input from the OR educators,
instruments; however, this will be included in the
AORN Journal j 131
rated the students success during the simulation

experiences and classroom activities. Class and
simulation laboratory and clinical experiences were
mandatory. If a student missed any class or clinical
experience, a make-up plan had to be implemented
to ensure that the student gained the required skills
and clinical experiences needed to pass the course.
The university faculty member, OR educators,
and preceptors were able to work very closely with
the students because there were only four students
in this pilot class. The individualized attention was
critical in the careful instruction and assessment
of each perioperative skill needed to successfully
complete the course. Reflections shared by the
students also were extremely valuable to faculty to
help promote positive student attitudes and also
intermingling of the students within the culture of
the OR.
EVALUATING THE PROGRAM
This innovative elective course resulted in many
positive outcomes. These include
n
n
n
n
n
development of an elective perioperative course

option for undergraduate nursing students,
increased interest in perioperative nursing,
identification of potential OR and/or surgical
nurse new hires for the hospital campus ORs,
a reduction in orientation and precepting time
needed for new hires, and
a reduction in hiring and orientation costs to the
hospital system.
The university added this course to the undergraduate nursing curriculum for a second J-term in
2014 and may consider offering it as a full semester
class in the future. Additionally, the university
intends to use this planning model to pilot other
elective courses for alternate specialty areas, such
as case management. The courses success has
increased the effectiveness of the partnership between the university and hospital system. The
cross-section of experience and knowledge within
the planning team offered a dynamic and diverse
group to help meet the programs goals.
132 j AORN Journal
BALLeDOYLEeOOCUMMA
Although a larger number of students completing
this pilot course would offer increased validity of the
identified outcomes, the positive effects of this
partnership are evident. The most notable outcome
for the hospital system was the increased interest in
perioperative nursing that led to two of the four
senior nursing students who completed the course
being hired by two of the hospital campuses. Hiring
these graduating nursing students reduced the
human resource costs of recruiting and hiring nurses
for the perioperative area. Orientation time for new
perioperative nurses can be extensive. Although the
nurse staffing numbers and vacancies may be lower
than within other hospital departments, the orientation length in the perioperative environment is
often five to six times longer (eg, the average orientation time usually reported in this hospital system for perioperative nurses is approximately six
to 12 months because of the intensity of skills required; D. Doyle, MS, RN, CNOR, NE-BC; in
person communication; December 12, 2013). Following the course experiences and interactions with
perioperative leaders and staff members, the orientation time for these two newly hired nurses was
determined to be four to eight months. The reduced
orientation time resulted in the newly hired nurse
becoming functional much sooner, which resulted
in improved productivity for both the preceptor and
the new nurse. Additionally, because the course
also eliminated the talent search process and reduced the application process, the hospital system
also realized a reduced cost in human resource
efforts. The exact dollar figure is undetermined, but
includes human resource and OR manager staffing
time for recruitment, interviewing, and the application process. The two students who did not
chose perioperative nursing went into other
areas. One went into intensive care nursing while
the other student is currently pursuing ministry
with plans that include also working as a perioperative nurse in the future.
Additional outcomes of this perioperative nursing
course included opportunities to offer senior
practicum and nursing electives in various specialty
www.aornjournal.org
Ambulatory Takeaways
Ambulatory Perioperative Nursing Programs
The shortage of nurses is critical in all practice settings, but especially in perioperative practice.
Approximately 75% of perioperative nurses are 50 years of age or older, and 65% will retire within the
next 10 years.1 Experts anticipate a perioperative nursing shortage if some type of clinical education is
not introduced to nursing students. Ball et al2 have described a program to address these issues.
Current education models do not offer an adequate amount of perioperative clinical experience
to nursing students. This lack of clinical exposure (eg, two days of observation versus four to six
weeks of clinical training for other specialties) combined with the limited resources and busy
schedules of managers in ambulatory surgical centers (ASCs) lead to new or inexperienced nurses
not being qualified for perioperative positions. Solutions are needed to address this issue of staffing
ORs with qualified perioperative nurses, but especially in the ASC setting.
One approach to recruiting nurses to a particular specialty practice area is to expose student nurses to the
specialty to gain skills and evaluate whether the specialty interests them. Many hospitals have started
offering specialty practice apprentice programs to student nurses during summer break to introduce them
to a specialty area. In a perioperative apprenticeship program, students undergo four weeks of didactic
learning on sterile technique, OR hazards, and basic OR skills. The students are then assigned to
participate, with supervision, in surgical procedures. Graduates of these programs often apply for positions
in the OR at which they apprenticed. Personnel in ASCs can implement programs like these to expand their
pool of nurses to recruit. Although these graduate nurses would need further clinical orientation after being
hired, they would have knowledge of the specialty and some practical skills, thus reducing the amount of
time required for their orientation. Another approach to recruiting ambulatory nurses is for ASCs to partner
with nursing schools to provide students with clinical opportunities in the ambulatory setting. Students
could elect to participate in these programs during their last six weeks of clinical experiences.
Ambulatory surgery centers often have less training and orientation resources available compared with
hospitals (eg, hiring outside educators, paying for staff members to attend conferences or programs) and
therefore must find economical yet effective solutions for orienting new staff members. A perfect resource is
AORNs Periop 101: A Core CurriculumTM.3 The training modules in this education program can serve as a
didactic resource for ASC personnel to use together with mentoring from experienced nurses in providing
new nurses with the cross-training needed to work in an ASC. In this manner, ASCs can participate in
educating students to the OR and also be proactive in responding to the perioperative nursing shortage.
Editors note: Periop 101: A Core Curriculum is a trademark of AORN, Inc, Denver, CO.
Brandi Cunningham, MBA, MHA, RN, BSN, is the administrator and director of nursing of a
single-specialty ASC in Winston-Salem, NC. Ms Cunningham has no declared affiliation that could
be perceived as posing a potential conflict of interest in the publication of this article.
1. Sherman RO, Patterson P, Avitable T, Dahl J. Perioperative nurse leader perspectives on succession planning: a call to action. Nurs
Econ. 2014;32(4):186-203.
2. Ball K, Doyle D, Oocumma N. Nursing shortages in the OR: solutions for new models of education. AORN J. 2015;101(1):115-136.
3. Periop 101: A Core CurriculumTM. AORN, Inc. http://www.aorn.org/Periop101/. Accessed September 16, 2014.
AORN Journal j 133
areas within the hospital system and improved

communication among and within perioperative
areas across the participating hospital campuses.
The improved communication included exciting
discussions regarding a systems approach to perioperative orientation, ongoing training, hiring, and
on-boarding practices.
Another opportunity arose as a result of the
J-term perioperative nursing course. During the
spring semester (which is the final semester before
graduation), the OR director allowed one senior
student who had not taken the J-term perioperative
course to take a senior practicum rotation in surgery. This practicum is fifteen weeks in length
because it extends across the entire spring semester.
This is different from the abbreviated three-week
J-term elective course; it offers more clinical experiences and the student has an assigned preceptor
and attends orientation sessions at the hospital facility to learn perioperative skills. The OR director,
who saw the value in the J-term course along with
the participating students excitement about perioperative nursing, allowed this senior practicum to
occur. As with the students who took the J-term
pilot course, the senior practicum student was also
offered a position in the OR on graduation and has
been assigned to the reduced orientation program.
This resulted in an additional savings because the
new nurse becomes a functioning member of the
team sooner.
The nursing students, university faculty, and
hospital system staff members all evaluated the
J-term perioperative course positively. Pre- and
posttest results of a survey given to the students
indicated increased confidence levels associated
with performing the perioperative skills introduced
during the course. Those skills involved basic OR
preparation, including gloving, gowning, and room
setup. Competent skill demonstration aligned with
the reported increase in confidence for OR roles,
equipment use, and patient positioning. Preceptors
and educators indicated increased student knowledge and abilities throughout the three-week term
for the course participants. Surgical educators and
134 j AORN Journal
BALLeDOYLEeOOCUMMA
preceptors indicated reduced personal anxiety related to hiring new graduates. The students consistently
reported that the relationships developed with the
preceptors and the OR educators contributed to
their increased confidence and their plans to seek
employment in a perioperative environment. Different from other perioperative courses, the application of Kolbs experiential learning theory to
simulated course experiences may have fostered the
students higher level of thinking and reflection and
therefore may have affected the faculty and staff
members positive observations and feedback.
The students also rated each of the AORN
Periop 101 modules they reviewed. Analysis of the
data showed that all modules received ratings from
3.25 to 4 on a 4-point Likert scale, with 4 being the
highest. The highest-rated module was Perioperative Assessment, and the lowest-rated modules
(even though these ratings were still very positive)
were Positioning the Surgical Patient and Surgical
Instruments. The students suggested that videos be
used to help understand the positioning practices
and devices in more detail. The students rated the
simulation experiences as the best learning activities in the course. They also rated the quiz that
challenged their knowledge to pick faulty practices
very highly and settings in the simulated intraoperative scene as contributing to the students
sense of a surgical conscience. One student, who
delivered the universitys 2013 student commencement address, proclaimed his experience as exceptional. Another student remarked, The course
brings in a breath of new, fresh air as we never were
given the opportunity to be fully exposed to the OR
in other courses. Yet another commented, I
would greatly recommend this course to other
students. The students also rated the clinical experiences very high and stated that they provided
valuable learning opportunities about the role of
the perioperative nurse. Students also gave the final
examination high ratings. They said that they much
preferred simulated testing compared with completing a written test. Faculty members are using
these comments along with face-to-face interviews

with the students completing the course to refine
future perioperative courses that will be offered at
the university.
Faculty identified two unforeseen outcomes
during the course implementation and evaluation
n
opportunities to offer a senior practicum and

nursing electives in various other specialty areas
within the hospital system, and
n ways to improve communication among perioperative areas across the participating hospital
campuses.
Other specialty areas within the hospital system
also are experiencing nursing shortages, and faculty
are exploring and conducting preliminary discussions to offer senior practicums and/or nursing
electives in these areas that follow the model of the
perioperative nursing course. These added courses
and experiences may assist in elevating the students interest in other nursing specialty areas that
are experiencing shortages.
The OR director and clinical educators also reported improved communication among their
various surgical areas. This collaboration expanded
across three hospital systems and four surgical
departments that were used to implement this
perioperative nursing course. Because of the regular and open communication, the OR educators
found commonalities among the different hospital
clinical sites, but more important, they found unexpected differences in practices and policies. In an
attempt to standardize across all hospital campuses,
the educators are collaboratively striving to create
consistency. This, in turn, could save the hospital
system money, time, and energy by reducing inconsistencies and redundancies in practice. In
addition, this unique collaboration can creatively
help to meet staffing needs in the OR for all campuses within the hospital system, even those not
directly involved with the course.
CONCLUSION
Members of the course planning committee added
advanced simulation technology to the perioperative
nursing coursework to create realistic perioperative
www.aornjournal.org
scenarios, and the nursing students involved with

this elective perioperative J-term course were able
to develop and demonstrate clinical judgment
without endangering real patients. The perioperative skill simulations appeared to contribute to the
students improved self-efficacy and confidence
levels which, in turn, was a factor for these students
in selecting perioperative nursing as a career focus.
If the university offers more courses that incorporate experiential learning theory methods and simulation that align with clinical experiences, positive
outcomes could affect the current and anticipated
nursing shortages in this specialty area and others.
This pilot course enabled the OR director to identify and hire nurses more quickly and move
them from new graduate status to full employment status in a shorter time. Partnerships between academia and hospital systems together
with innovative methods of teaching and learning
can help solve the major challenge of staffing ORs
in the future.
Editors note: Periop 101: A Core Curriculum is a
References
1. Holmes SP. Implementing a perioperative nursing elective in a baccalaureate curriculum. AORN J. 2004;80(5):
902-910.
2. Blegeberg B, Blomberg A, Hedelin B. Nurses conceptions of the professional role of operating theatre and
psychiatric nurses. V
ard i Norden. 2008;28(3):9-13.
3. Thompson JA. Why work in perioperative nursing? Baby
boomers and Generation Xers tell all. AORN J. 2007;
86(4):564-586.
4. Messina BM, Ianniciello JM, Escallier LA. Opening the
doors to the OR: providing students with perioperative
clinical experiences. AORN J. 2011;94(2):180-188.
5. Sherman RO, Patterson P, Avitable T, Dahl J. Perioperative nurse leader perspectives on succession planning: a
call to action. Nurs Econ. 2014;32(4):186-203.
6. Happell B. Student interest in perioperative nursing practice as a career. AORN J. 2000;71(3):600-605.
7. New Zealand Nurses Organisation. Shortage of perioperative nurses predicted. Kai Tiaki Nurs N Z. 2010;16(9):
9. http://www.highbeam.com/doc/1G1-241179347.html.
Accessed August 4, 2014.
8. Ruth-Sahd LA, Wilson G. Collaborative educational
initiative: developing and implementing a perioperative
nursing course for baccalaureate nursing students. J Perianesth Nurs. 2013;28(2):59-66.
AORN Journal j 135
9. Dickinson J. Cant find nurses for your program? These

surgery programs grow their own. Same Day Surg. 2014;
38(Suppl 1):S1-S4.
10. Trice TB, Brandvold C, Bruno E. Practice and education:
partnering to address the perioperative nursing shortage.
AORN J. 2007;86(2):259-264.
11. Stren I, Hanssen I. Why do nurses choose to work in the
perioperative field? AORN J. 2011;94(6):578-589.
12. Wilson G. Redesigning OR orientation. AORN J. 2012;
95(4):453-462.
13. Randa K, Heiser R, Gill R. Strategic investments in the
operating room: information technology to generate rapid
ROI and long-term competitive advantage. August 2009.
HIMMS.org. http://www.himss.org/files/HIMSSorg/
content/files/SIS_Strategic_Investments_in_the_OR%
20White%20Paper.pdf. Accessed August 4, 2014.
14. Bacon DR. Results of the 2012 AORN salary and
compensation survey. AORN J. 2012;96(6):588-603.
15. Americas Best Colleges. 2012. U.S. News & World
Report. http://colleges.usnews.rankingsandreviews.com/
best-colleges?int994d08. Accessed August 4, 2014.
16. Moskowitz M, Levering R. The 100 best companies to
work for. Fortune. 2014;169(2):108.
17. 15 Top Health Systems: Study Overview. 4th ed. Ann
Arbor, MI: Truven Health Analytics Inc; 2012. http://
img.en25.com/Web/TruvenHealthAnalytics/Truven_15_
Top_Health_Systems_2012_Abstract.pdf. Accessed
August 4, 2014.
18. American Association of Colleges of Nursing. The Essentials of Baccalaureate Education for Professional
Nursing Practice. Washington, DC: American Association of Colleges of Nursing; 2008.
19. Perioperative Standards and Recommended Practices.
Denver, CO: AORN, Inc; 2014.
20. Lisko SA, ODell V. Integration of theory and practice:
experiential learning theory and nursing education. Nurs
Educ Perspect. 2010;31(2):106-108.
21. Kolb DA. Experiential Learning: Experience as the
Source of Learning and Development. Englewood Cliffs,
NJ: Prentice Hall; 1984. http://academic.regis.edu/ed205/
kolb.pdf. Accessed August 4, 2014.
22. Kinyon J, Keith CB, Pistole MC. A collaborative approach
to group experiential learning with undergraduate nursing
students. J Nurs Educ. 2009;48(3):165-166.
23. Mullen L, Byrd D. Using simulation training to improve
perioperative patient safety. AORN J. 2013;97(4):419-427.
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24. Scherer YK, Bruce SA, Graves BT, Erdley WS. Acute
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25. Bambini D, Washburn J, Perkins R. Outcomes of clinical
simulation for novice nursing students: communication,
confidence, clinical judgment. Nurs Educ Perspect. 2009;
30(2):79-82.
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27. Periop 101: The Essential Perioperative Nursing
Program. AORN, Inc. http://www.aorn.org/periop101/.
Accessed August 14, 2014.
Kay Ball, PhD, RN, CNOR, FAAN, is an

associate professor of nursing at Otterbein
University, Westerville, OH, and past president
of AORN. Dr Ball has no declared affiliation
that could be perceived as posing a potential
conflict of interest in the publication of this
article.
Donna Doyle, MS, RN, CNOR, NE-BC, is
administrative director of surgery and anesthesia
at Grant Medical Center, Columbus, OH. Ms
Doyle has no declared affiliation that could
Nichole I. Oocumma, BSDH, MA, CHES,
CHSE, is director of learning, OhioHealth, CareConnect Training, Columbus, OH. Ms Oocumma
has no declared affiliation that could be perceived
as posing a potential conflict of interest in the
SPECIAL REPORT
A Perspective on Surgical Site Infection Prevention
The Role of the OR

Environment in Preventing
Surgical Site Infections
MAUREEN SPENCER, MEd, BSN, RN, CIC; CHARLES E. EDMISTON, JR, PhD, CIC
ospital environments can be a source for

the acquisition and spread of pathogens.1-10
Pathogens are inherently present in the
surgical setting, and several significant health caree
associated pathogens can be transferred from patient to patient, from health care worker to patient
or vice versa, and from surfaces to patients or
health care workers and cause surgical site infections (SSIs). These pathogens (eg, methicillinresistant Staphylococcus aureus [MRSA], S aureus,
vancomycin-resistant enterococci, Acinetobacter
species) may survive on environmental surfaces for
weeks or months.2,3 In fact, Clostridium difficile
spores can persist on environmental surfaces for up
to five months.1 The increase in multidrug-resistant
organisms is contributing to additional risk in the
surgical setting. For example, MRSA and other
drug-resistant pathogens cause serious and potentially life-threatening infections (eg, pneumonia,
bloodstream infections, SSIs) and increase health
careeassociated infection (HAI) rates in health
care facilities. Several studies demonstrated cross
infection when a patient was admitted to a room
from which a patient colonized or infected with
these environmental pathogens was just discharged.4,5
Recent research has identified a number of problems
and associated strategies to mitigate infection concerns in the surgical setting. These strategies include
using a bundled approach to decrease MRSA and
HAI transmission rates, implementing measures to
reduce the risk from airborne contaminants, expanding environmental cleaning protocols to address all
surfaces in large hybrid ORs, implementing methods
to decrease turnover time without increasing the risk
of HAIs, implementing ultraviolent (UV) technology
during terminal cleaning, and following the manufacturers instructions for use (IFU) during instrument
reprocessing in the sterile processing department.
STAPHYLOCOCCUS AUREUS AND OTHER
MULTIDRUG-RESISTANT ORGANISMS
Staphylococcus aureus is considered to be the
most significant pathogen associated with SSIs.11
Epidemiological studies have shown that most SSIs
are caused by strains of S aureus that are brought
into the hospital environment by patients themselves.12 Because S aureus is a significant cause
of SSIs and is inherently present in the health
care setting, the perioperative environment itself
can be a potential risk factor for SSI. Because
of this, environmental risk reduction strategies
are key in helping protect patients from SSIs
related to S aureus and other pathogens in the
surgical setting.
In health care settings, MRSA can cause serious
and potentially life-threatening infections, such as
pneumonia, bloodstream infections, and SSIs. In
2007, the Veterans Administration implemented
the MRSA Prevention Initiative (now called the
MDRO Prevention Initiative), which resulted in
AORN, Inc, 2014
December 2014
Vol 100
No 6
AORN Journal j 603
December 2014 Vol 100 No 6
significant decreases in the transmission of MRSA

as well as decreases in HAI rates in hospitals.13
Results showed a 17% decrease for intensive care
units and 21% for noneintensive care units. The
MDRO Prevention Initiative uses a bundled approach whereby health care providers
n
n
n
n
use gowns and gloves when caring for patients

colonized or infected with MRSA,
clean rooms thoroughly with a low-linting
cloth and Environmental Protection Agencye
registered disinfectant products in the concentration indicated in the manufacturers IFU,14
isolate colonized or infected patients and their
linens,
implement and maintain an institutional culture
that focuses on individual responsibility for
infection control, and
screen every patient undergoing high-risk surgery (eg, orthopedic, cardiac, implant procedures)
for MRSA.13
AIRBORNE SOURCES OF WOUND

CONTAMINATION
A number of studies have identified the airborne
route as a significant exogenous source for intraoperative surgical wound contamination.15-17 In
addition, endogenous contamination can occur from
the patients own flora, either during surgery or
during the postoperative period. Some strategies
that have shown promise for reducing airborne
contaminants include the use of
n
n
n
n
n
laminar air flow ventilation,

traffic control and limiting personnel in the OR,
exhaust suits,
surgical attire for complete hair and body coverage,
smoke evacuators for procedures in which the
electrosurgical unit or laser is used (eg, tissue
ablation procedures), and
UV lights to kill airborne contaminants.15-17
ENVIRONMENTAL CLEANING IN A
HYBRID OR
Interest in hybrid ORs has grown in recent years,
fueled by the rising demand for minimally invasive
604 j AORN Journal
SPECIAL REPORT: OR ENVIRONMENT

surgery and the ever more complex nature of
interventional imaging. The term integrative approach
in an OR is defined as a room in which all the
different equipment is designed to work together in
harmony, thus providing increased efficiency and
better patient care. Hybrid is defined as a room
serving both diagnostic and surgical functions in
the same location. A hybrid OR is equipped with
advanced medical imaging devices, such as a fixed
fluoroscopy unit, computed tomography scanners,
or magnetic resonance imaging scanners. Hybrid
ORs, by their sheer size and the volume of equipment, pose a challenge for perioperative personnel
with regard to infection prevention.
A traditional OR is approximately 600 to 700
square feet, whereas new hybrid rooms often are a
minimum of 1,000 square feet, in addition to the
space used as an equipment room and control room.
Taking into account these separate rooms, the
typical size is 1,200 square feet. Hybrid ORs also
must accommodate two teams of clinicians, bridging
two separate disciplines, resulting in as many as 26
people in the room at one time. In addition to being
nearly double the size of typical ORs, hybrid ORs
use more utilities, require shielding for the radiology
equipment, and need structural support for the large
equipment booms. These larger ORs have many
exposed surfaces that must be cleaned and disinfected between procedures and terminally disinfected at the end of the day.
Environmental cleaning and disinfection is a
team approach that should involve environmental
department and perioperative personnel.14-20 The
perioperative nurse is responsible for ensuring
a safe and clean environment before surgery by
performing a visual inspection before case carts,
supplies, equipment, and instruments are brought
into the room.14 This is especially important in
hybrid ORs because of the large size and the increased time it takes to clean them compared with
a standard OR. All horizontal surfaces in the OR
should be damp dusted before the first scheduled
surgical procedure of the day, which includes
furniture, surgical lights, booms, and radiology
SPENCEReEDMISTON
www.aornjournal.org
should be easily accessible and ready to be used.

Fast-drying disinfectants are now available for use
in the OR, which decreases required contact times;
some have reduced contact times of two to five
minutes. Disposable, lint-free, single-use cloths
immersed in germicidal containers can be used for
cleaning during room turnover. Their use makes
the wipe-down process more efficient. However,
personnel must use as many cloths as necessary to
ensure that an adequate quantity of the germicidal
SAFELY IMPROVING OR TURNOVER
product comes in contact with every surface being
EFFICIENCY
cleaned for the appropriate dwell time (ie, the
An important concept in improving turnover timesd
amount of time required for contact of a chemical
and therefore improving efficiency and saving time
agent with a surface)
and money for all
according to the manperioperative team
membersdis creating
Environmental cleaning and disinfection is a team ufacturers IFU.
It may be possible
multidisciplinary teams approach that should involve environmental
to consider disconto clearly identify the
department and perioperative personnel.
tinuing the practice
roles associated with
of routinely mopping
procedure setup and
floors between every procedure even when there
breakdown and determine which activities may
was no possibility of splash or splatter of blood
safely be conducted simultaneously. Turnover times
or body fluids, such as from irrigation. However,
must be sufficient to allow personnel to thoroughly
personnel must keep in mind that fluid contamiclean and disinfect surfaces that have come in contact
nation may have dried and may not always be
with the patient or are visibly soiled (eg, blood, tisvisible. When there is any doubt, the traffic area
sue) from the surgical procedure. Although reduction
should be mopped. It is the RN circulators rein turnover time is important for surgical throughput,
sponsibility to make this decision on a case-bythis can be enhanced with the use of new disinfectants
case basis. Examples of procedures that may not
that require less contact time.
require mopping the floor are pain injection or
Competent perioperative team members should
cataract procedures for which no irrigation is
participate in turning over the room, positioning the
used and there is little, if any, risk of contamipatient, placing the tourniquet, performing the
nating the floor with blood or other potentially insurgical skin prep, holding limbs for prepping and
fectious materials. Deciding not to mop the floor
positioning, connecting and disconnecting specialafter this type of procedure could help decrease
ized equipment, preparing instruments and supplies
turnover time by eliminating the need to spend
for subsequent procedures, and assisting anesthesia
the time mopping the floor and allowing for the
team members with setup and breakdown. The
required disinfectant contact time.
more efficiently the multidisciplinary teamwork
Manufacturers of OR turnover equipment are
is managed, the faster the room turnover times
assisting in this process by designing packaged kits
will be.
with disposable linens, trash bags, hamper liners,
By analyzing every task performed in room
kick bucket liners, wiping cloths, and mops deturnover and mapping out the process, perioperasigned to fit the unique needs of each hospital. These
tive personnel can more effectively assign tasks
kits provide standardization of the process of room
to everyone. Cleaning and disinfecting equipment
equipment. Plasma and monitor screens should
be cleaned according to manufacturers IFU.14
Reduction in disinfectant time is important to
process improvement teams as they attempt to
decrease turnaround time in the OR and enhance
surgical throughput. Some manufacturers have
produced disinfectants that reduce the 10-minute
contact time to two minutes.
AORN Journal j 605
high-level disinfection of endoscopes. Turnaround

times are decreasing with surgical throughput to
generate revenue. This can make the challenge even
more complex for sterile processing department
personnel. An outbreak of Pseudomonas aeruginosa
related to improperly cleaned and sterilized arthroUV TECHNOLOGY DURING TERMINAL
CLEANING
scopic shavers and cannulas occurred in a Texas
Research has shown that current strategies for
hospital in 2009.21 A cluster of seven organ-space
terminal disinfection of hospital rooms are
SSIs caused by P aeruginosa occurred after arthroinadequate, and more than 50% of hospital
scopic procedures performed between April 22,
surfaces may go untouched and uncleaned.6,7
2009, and May 7, 2009. During the investigation that
Therefore, hospitals are evaluating and using UV
followed, investigators inspected the lumens of
light in the C-band spectrum (UV-C) as a novel
arthroscopic instruments by using a borescope (ie, a
method to enhance terminal disinfection of hospital
3-mm clinical endoscope). The investigators then
rooms and ORs. By deactivating DNA in bacteria,
evaluated the arthroscope cleaning procedure. The
dust mites, viruses, and other pathogens, UV-C light
process being followed at the facility involved
is germicidal and destroys the ability of pathogens to
briefly submersing the instrument in enzymatic somultiply and cause disease. This process, however,
lution, wiping down the instrument, and then prodoes not naturally
cessing the instrument
occur indoors. In one
with high-level disinstudy, UV lighting
fection, even though
In one study, UV lighting appeared to be an
appeared to be an
effective way to lower the risk of infection in the the manufacturers
effective way to lower OR during total joint replacement surgery.
IFU recommended
the risk of infection in
gross decontamination
the OR during total
with submersion in
joint replacement surgery.8 Another study showed
enzymatic solution for 10 to 15 minutes before lowthat UV-C light can effectively eradicate MRSA,
temperature sterilization. The investigators inspected
vancomycin-resistant enterococci, Acinetobacter
the instruments and discovered remnants of tissue
species, and C difficile under experimental conand bioburden in each of the evaluated handpieces
ditions.9 Another study confirmed that the autoand the inflow/outflow cannula lumen after reprocessmated UV-C emitter reduced the bioburden of
ing. Bacterial contamination of surgical instruments
MRSA, vancomycin-resistant enterococci, and C
likely survived the sterilization process because of
10
difficile in clinical settings. As this technology
residual tissue within the lumens of the arthroscopic
further develops for practical use in the health
instruments.
care setting, room decontaminators that use
This outbreak prompted collaboration between
UV-C light may be integrated into OR terminal
the US Food and Drug Administration and Centers
disinfection processes to help reduce the risk
for Disease Control and Prevention to protect paof SSIs.
tients undergoing arthroscopic procedures. On July
7, 2009, the Food and Drug Administration released
a Safety Alert regarding concerns about retained
STERILE PROCESSING PRACTICES
tissue within arthroscopic shavers despite reprocThe increasing complexity of surgical instruments
essing according to the manufacturers recommenhas complicated instrument cleaning processes. This
dations.22 This outbreak and others also have led
poses increasing challenges for clinicians to adeto increased scrutiny in the sterile processing
quately sterilize surgical instruments and perform
turnover and help ensure the right equipment is
accessible to clean and disinfect the room properly
so turnover is expedited without compromising
infection prevention efforts.
606 j AORN Journal
SPENCEReEDMISTON
department during surveys by The Joint Commission
and Centers for Medicare & Medicaid Services.
One of the most important practices associated
with reprocessing complex surgical instruments is
following the manufacturers IFU and making sure
they are available in the area where the instruments
will be reprocessed, whether that is the sterile
processing department or the OR. The manufacturers IFU provide detailed information related to
critical reprocessing elements such as brush type,
water temperature, and enzymatic solution, as well
as detailed cleaning procedures. Many national
organizations, including the Association for the
Advancement of Medical Instrumentation23 and
AORN,24 recommend following the manufacturers
IFU. AORN recommends that devices should be
cleaned, decontaminated, inspected, packaged,
sterilized, and stored in a controlled environment in
accordance with the manufacturers written IFU.24
In addition, AORN recommends that the manufacturers IFU for handling and reprocessing should
be obtained and evaluated before purchasing surgical instruments to ensure that the equipment
can be cleaned and reprocessed in the health care
facility.24,25
PERIOPERATIVE NURSING IMPLICATIONS
Perioperative nurses play a vital role in helping to
ensure a clean and safe environment in the surgical
suite. In addition to practicing good hand hygiene,
perioperative personnel must address potential infection issues caused by having patients in the
preoperative holding area who require isolation
precautions; the environment must be thoroughly
cleaned and disinfected between each patient. Daily
routine cleaning of the environment is a shared
endeavor between perioperative and environmental
department personnel. In the OR, RN circulators
ensure that room turnover is performed properly
and terminal cleaning is performed on a daily basis.
All equipment being brought into an OR has to
be wiped down with a disinfectant to remove dust
and contaminants. In the postanesthesia care unit,
nurses ensure that the environment is kept clean
www.aornjournal.org
and personnel disinfect bedside tables and other

equipment between patients. Infection control and
prevention in the perioperative setting requires
teamwork to help ensure a clean environment.
CONCLUSION
The most important prevention measure is simple
hand hygiene, but many factors contribute to the
development of an SSI. Infection prevention is
everybodys responsibility, including surgeons,
perioperative nurses, anesthesia professionals, and
ancillary personnel. Thus, strong teamwork is essential in making surgery safe for patients. The
formation of a multidisciplinary team is essential to
address the following factors:
n
Strive to eliminate all pathogens from the perioperative environment with use of state-of-theart cleaning products and strict adherence to
evidence-based processes.
n Use varied strategies to reduce airborne contaminants in the perioperative environment.
n Evaluate the use of UV-C light to enhance
terminal disinfection of ORs.
n Ensure that manufacturers IFU are followed
when reprocessing complex surgical instruments.
It takes teamwork, leadership, accountability, and
commitment to make the OR a safe environment
that is free of exogenous contaminants and to ensure that personnel adhere to aseptic techniques and
practices.
References
1. Kim KH, Fekety R, Batts DH, et al. Isolation of Clostridium difficile from the environment and contacts of
patients with antibiotic-associated colitis. J Infect Dis.
1981;143(1):42-50.
2. Neely AN, Maley MP. Survival of enterococci and
staphylococci on hospital fabrics and plastic. J Clin
Microbiol. 2000;38(2):724-726.
3. Weber DJ, Rutala WA. Role of environmental contamination in the transmission of vancomycin-resistant enterococci. Infect Control Hosp Epidemiol. 1997;18(5):306-309.
4. Datta R, Platt R, Yokoe DS, Huang SS. Environmental
cleaning intervention and risk of acquiring multidrugresistant organisms from prior room occupants. Arch
Intern Med. 2011;171(6):491-494.
5. Huang SS, Datta R, Platt R. Risk of acquiring antibioticresistant bacteria from prior room occupants. Arch Intern
Med. 2006;166(18):1945-1951.
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6. Carling PC. Evaluating the thoroughness of environmental cleaning in hospitals. J Hosp Infect. 2008;68(3):
273-274.
7. Carling PC, Parry MF, Von Beheren SM. Identifying
opportunities to enhance environmental cleaning in 23
acute care hospitals. Infect Control Hosp Epidemiol.
2008;29(1):1-7.
8. Ritter MA, Olberding EM, Malinzak RA. Ultraviolet
lighting during orthopaedic surgery and the rate of
infection. J Bone Joint Surg Am. 2007;89(9):1935-1940.
9. Nerandzic MM, Cadnum JL, Pultz MJ, Donskey CJ.
Evaluation of an automated ultraviolet radiation device
for decontamination of Clostridium difficile and other
healthcare-associated pathogens in hospital rooms. BMC
Infect Dis. 2010;10:197.
10. Boyce JM, Havill NL, Moore BA. Terminal decontamination of patient rooms using an automated mobile UV
light unit. Infect Control Hosp Epidemiol. 2011;32(8):
737-742.
11. Sievert DM, Ricks P, Edwards JR, et al. Antimicrobialresistant pathogens associated with healthcare-associated
infections: summary of data reported to the National
Healthcare Safety Network at the Centers for Disease
Control and Prevention, 2009-2010. Infect Control Hosp
Epidemiol. 2013;34(1):1-14.
12. Sexton T, Clarke P, ONeill E, Dillane T, Humphreys H.
Environmental reservoirs of methicillin-resistant Staphylococcus aureus in isolation rooms: correlation with
patient isolates and implications for hospital hygiene.
J Hosp Infect. 2006;62(2):187-194.
13. Jain R, Kralovic SM, Evans ME, et al. Veterans Affairs
initiative to prevent methicillin-resistant Staphylococcus
aureus infections. N Engl J Med. 2011;364(15):1419-1430.
14. Recommended practices for environmental cleaning. In:
Perioperative Standards and Recommended Practices.
Denver, CO: AORN, Inc; 2014:255-276.
15. Edmiston CE, Seabrook GR, Cambria RA, et al. Molecular epidemiology of microbial contamination in the
operating room environment: is there a risk for infection? Presented at the 62nd Annual Meeting of the
Central Surgical Association; Tucson, AZ; March
10-12, 2005.
16. Whyte W, Hodgson R, Tinkler J. The importance of
airborne bacterial contamination of wounds. J Hosp
Infect. 1982;3(2):123-135.
17. Lidwell OM, Lowbury EJ, Whyte W, Blowers R, Stanley SJ,
Lowe D. Airborne contamination of wounds in joint
replacement operations: the relationship to sepsis rates.
J Hosp Infect. 1983;4(2):111-131.
18. Allen G. Implementing AORN recommended practices for
environmental cleaning. AORN J. 2014;99(5):570-582.
19. Spruce L. Back to basics: environmental cleaning. AORN
J. 2014;100(1):54-64.
608 j AORN Journal

20. Jefferson J, Whelan R, Dick B, Carling P. A novel
technique for identifying opportunities to improve
environmental hygiene in the operating room. AORN J.
2011;93(3):358-364.
21. Tosh PK, Disbot M, Duffy JM, et al. Outbreak of Pseudomonas aeruginosa surgical site infections after arthroscopic procedures: Texas, 2009. Infect Control Hosp
Epidemiol. 2011;32(12):1179-1186.
22. Arthroscopic shavers: ongoing safety review [archived
content]. US Food and Drug Administration. http://
www.fda.gov/Safety/MedWatch/SafetyInformation/Safety
AlertsforHumanMedicalProducts/ucm170730.htm. July 7,
2009. Updated July 7, 2009. Accessed September 19, 2014.
23. Association for the Advancement of Medical Instrumentation. ANSI/AAMI ST79:2013dComprehensive
Guide to Steam Sterilization and Sterility Assurance in
Health Care Facilities. Arlington, VA: Association for
the Advancement of Medical Instrumentation; 2013.
24. Recommended practices for sterilization. In: Perioperative Standards and Recommended Practices. Denver,
CO: AORN, Inc; 2014:575-602.
25. Recommended practices for cleaning and care of surgical
instruments and powered equipment. In: Perioperative
Standards and Recommended Practices. Denver, CO:
AORN, Inc; 2014:541-560.
Maureen Spencer, MEd, BSN, RN, CIC, is a

national infection preventionist consultant for
Infection Prevention Consultants, Boston, MA.
Ms Spencer has no declared affiliation that could
Charles E. Edmiston, Jr, PhD, CIC, is a professor of surgery and the director of the Surgical
Microbiology Research Laboratory at the Medical
College of Wisconsin, Milwaukee. Having received payment for providing expert testimony/
lectures for Ethicon, CareFusion, and the Florida
Hospital Association, and having received institutional grant money from CareFusion, Dr
Edmiston has declared affiliations that could
be perceived as posing potential conflicts of
Back to Basics:
Implementing the Surgical
Checklist
1.7
www.aorn.org/CE
Approvals
indicates that continuing education (CE) contact hours

are available for this activity. Earn the CE contact hours by
reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner
Evaluation at http://www.aorn.org/CE. Each applicant who
successfully completes this program can immediately print
a certificate of completion.
relicensure.
Event: #14542
Session: #0001
The CE contact hours for this article expire November 30,

2017. Pricing is subject to change.
Purpose/Goal
To provide the learner with knowledge of best practices related
to implementing a surgical checklist.
Objectives
1. Discuss common areas of concern that relate to perioperative best practices.
2. Discuss best practices that could enhance safety in the
perioperative area.
3. Describe implementation of evidence-based practice in
relation to perioperative nursing care.
Lisa Spruce, DNP, RN, ACNS, ACNP, ANP, CNOR, has

no declared affiliation that could be perceived as posing
a potential conflict of interest in the publication of this
article.
by Helen Starbuck Pashley, MA, BSN, CNOR, clinical
editor, with consultation from Susan Bakewell, MS, RN-BC,
director, Perioperative Education. Ms Starbuck Pashley and
Ms Bakewell have no declared affiliations that could be
perceived as posing potential conflicts of interest in the publication of this article.

article.
Disclaimer
Accreditation
in the activity.
AORN, Inc, 2014
November 2014
Vol 100
No 5
AORN Journal j 465
Back to Basics:
Implementing the Surgical
Checklist
1.7
www.aorn.org/CE
ABSTRACT
Surgery is complex and technically demanding for all team members. Surgical
checklists have been implemented with different degrees of success in the perioperative setting. There is a wealth of evidence that they are effective at preventing patient
safety events and helping team members master the complexities of modern health
care. Implementation is key to successful use of the surgical checklist in all invasive
procedural settings. Key strategies for successful checklist implementation include
establishing a multidisciplinary team to implement the checklist, involving surgeon
leaders, pilot testing the checklist, incorporating feedback from team members to
improve the process, recognizing and addressing barriers to implementation, and offering coaching and continuous feedback to team members who use the checklist.
Using these strategies will give the perioperative nurse, department leaders, and surgeons the tools to implement a successful checklist. AORN J 100 (November 2014)
Key words: surgical checklist, time out, surgical errors, preventing surgical error.
n 2009, Atul Gawande, MD, authored The

Checklist Manifesto, a ground-breaking look at
the fact that health care and medicine have become so complex and specialized, they are difficult
for humans to master.1 Every year, 50 million
surgeries are performed, and Gawande points out
that 150,000 patients die each year after undergoing
surgery. This is more than three times the number
of deaths attributed to traffic accidents.1 Many of
these surgical deaths are avoidable and preventable
through the use of the surgical checklist.
We use checklists in everyday life, from a simple recipe to a grocery list, and we check off
the steps and ingredients to make sure nothing is
forgotten. The professional use of checklists is not

new, but it developed in the aviation industry, not
in health care. In the 1930s, Boeing developed a
pilots checklist because new planes, at the time,
were being developed with complicated flight instructions that were too complex to be left to pilot
memory.1 The pilots of these new planes went on to
fly 1.8 million times without incident.1 Fast forward to 2014. The surgical checklist has been in
use in almost every OR throughout the United
States and the world. Surgical checklists have
been created by The Joint Commission, 2 the
World Health Organization3 (WHO) (Figure 1), the
Surgical Patient Safety System (SURPASS),4 and
466 j AORN Journal
November 2014 Vol 100
No 5
AORN, Inc, 2014
Figure 1. The WHO Surgical Safety Checklist. Reprinted with permission from the World Health Organization, Geneva, Switzerland.
BACK TO BASICS: SURGICAL CHECKLIST

www.aornjournal.org
AORN Journal j 467
AORN (Figure 2).5 The question is, how are they

working?
THE SURGICAL CHECKLIST
In December 2012, Borchard et al6 published a
systematic review that assessed the compliance,
effectiveness, and critical factors needed for implementing surgical checklists. The review included
22 articles that met the study selection criteria.
The collective evidence showed that when a surgical checklist is used, the relative riskdthat is, the
risk of a particular event occurring for different
groups of people7dfor mortality is 0.57 and the
risk of any complication is 0.63. The overall
checklist compliance rate in the review ranged
from 12% to 100%, and time-out compliance rates
were 70% to 100%. The investigators concluded
that checklists were effective and economical tools
to decrease morbidity and mortality in the surgical setting.6
Researchers in the Netherlands published a
retrospective cohort study in 2012 that analyzed
all adult surgical patients who required hospital
admission at a university medical center.8 The main
purpose of the study was to examine in-hospital
mortality before and after implementation of the
WHO surgical checklist. The researchers measured
crude mortality, which is the number of deaths in a
population during a specific period using the total
population at the midpoint of the period as the
denominator in the calculation, as well as mortality,
which is the overall death rate without consideration of the number of people in the population.
After implementation of the checklist, crude mortality decreased from 3.13% to 2.85%; after adjusting
for baseline differences (eg, patient characteristics,
surgical specialty, comorbidities), the researchers
showed that mortality also was significantly decreased (odds ratio, 0.85; 95% confidence interval, 0.73-0.98). The beneficial effects were strongly
related to checklist completion and compliance.
In 2013, Lubbeke et al9 conducted a quasiexperimental prestudy that looked at measures
468 j AORN Journal
SPRUCE
No 5
used before checklist implementation and a

poststudy to evaluate postimplementation measures. Both phases of the study evaluated the
effectiveness of an intraoperative checklist in highrisk surgical patients. The environment of this
study had a high standard of surgical care with
regular, long-held perioperative patient safety programs. The researchers measured unplanned returns
to the OR for any reason, unplanned admission to
an intensive care unit (ICU), reoperation for surgical site infection (SSI), and in-hospital deaths
within 30 days of surgery. They included a total of
2,427 surgical interventions: 609 performed before
and 1,818 performed after implementation of
a checklist.
When comparing preimplementation and postimplementation data, researchers noted that
there were
n
45/609 (7.4%) unplanned returns to the OR

within 30 days versus 109/1,818 (6.0%),
n 18/609 (3.0%) reoperations for SSI versus
30/1,818 (1.7%),
n 17/609 (2.8%) unplanned admissions to the
ICU versus 48/1,818 (2.6%), and
n 26/609 (4.3%) in-hospital deaths versus
108/1,818 (5.9%).
The investigators concluded that there was a trend
toward a reduction of reoperations for SSI, but they
noted no other checklist influence.9
Treadwell et al10 conducted a systematic review
of the literature in 2014 and looked for studies
that described use of the WHO checklist, the
SURPASS checklist, any wrong-site surgery
checklist, or an anesthesia checklist. They included
33 studies that obtained a variety of outcomes.
They found that safety checklists have been
implemented in a wide variety of settings. The review demonstrated that surgical safety checklists
are associated with a decrease in surgical complications, an increase in detecting potential safety
hazards, and an improvement in communication
among team members.10
Figure 2. The AORN Comprehensive Surgical Checklist. Reprinted with permission from AORN, Inc. Copyright 2014. All rights reserved.

www.aornjournal.org
AORN Journal j 469
A 2014 Canadian study conducted by Urbach

et al11 had a different conclusion. The investigators
surveyed all acute care hospitals in Ontario to
determine whether a surgical safety checklist had
been implemented and looked at data before and
after checklist implementation. The investigators
compared surgical mortality, rate of surgical complications, length of hospital stay, and rates of
hospital readmission and emergency department
visits within 30 days after discharge in a variety
of surgical patients and concluded that there was
no significant reduction in mortality or surgical
complications when a surgical checklist was
implemented.11
All but one of these studies suggested that
implementation of a surgical safety checklist is
beneficial in improving surgical outcomes, mortality rates, and complications. With regard to the
study by Urbach et al,11 Lucian Leape, MD, stated
that it is not the act of ticking off a checklist
that reduces complications, but performance
of the actions it calls for.12(p1063) That is, the
checklist is a tool, but patient safety depends on
team interaction and team communication. Team
members must introduce themselves and have
a discussion about critical surgical steps and
concerns of team members. Dr Leape hypothesized
that the reason for the failure of the surgical
checklist in the Ontario study was that it was not
actually used.12(p1064)
In 2011, Conley et al13 conducted a survey
of surgical checklist implementation in five
Washington state hospitals and found that a
key component of successful implementation
was explaining the rationale behind use of a
checklist and adequately demonstrating its use.
HOW-TO GUIDE
Checklists have been proven to be effective in
many situationsdfrom flying an airplane to using
a recipe in the kitchen to performing a surgical
time out. The fact remains, however, that full implementation may not be occurring. Many perioperative
470 j AORN Journal
SPRUCE
No 5
nurses struggle to get buy-in and compliance from

other perioperative team members and become
frustrated when efforts to complete the checklist
are thwarted.
Conley et al13 suggest taking the following steps
to implement a checklist in the surgical setting:
n
n
n
n
n
n
n
Begin implementation by forming a multidisciplinary team led by surgeons and nursing

leaders.
Obtain buy-in from senior facility leaders.
Arrange for the multidisciplinary team to
meet two or three times per week to plan and
strategize.
Have surgeon leaders head the initiative because perioperative team members will listen
to known surgeon leaders more readily than
leaders whom they do not know well.
Conduct informal surgeon-to-surgeon conversations surrounding checklist implementation.
Use one surgeon or one service line to pilot test
the checklist process and make changes based
on feedback.
Form a surgical checklist implementation
team for every surgical discipline and provide
extensive training to all perioperative team
members.
Offer real-time coaching to assist surgeons
and other team members with using the
checklist.
Have champions of the checklist who observe
the process offer continuous feedback to all
perioperative team members.
Welcome and respond to all staff member
input.
Recognize and address barriers to implementation,
such as requiring all team members signatures on
the checklist. Instead, only require the RN circulator to affirm the checklist was completed.
BENEFITS
The effect of surgical checklists on patients and
their safety has been demonstrated in many
www.aornjournal.org
Figure 3. This Whats Wrong with This Picture? illustration suggests some of the reasons that checklists fail to
prevent surgical errors.
studies.6,8-10,13 The true effect on patient safety is

based on whether the checklist is performed and
how effectively team members implement it. Safer
care can only be achieved if perioperative team
members recognize the importance of working as
a team, using effective team communication, and
using the checklist as a tool to bring the team
together in a true patient safety effort. Figure 3
provides an illustration of some of the reasons
that team members fail to conduct a checklist
correctly.
STRATEGIES FOR SUCCESS

Although the value of a checklist may be understood, there are ways to help ensure successful
implementation. Some of the following ideas can
be used to successfully implement a checklist in the
surgical setting.
n
Make implementation easy by providing a

laminated checklist, a checklist board, or an
electronic checklist that all team members can
see easily.
AORN Journal j 471

n
n
n
No 5
SPRUCE
anticipate any problems or issues that could

arise.
n Read from the checklist every timeddo not rely
on memory.
n Make sure leaders understand
n the research supporting checklist implementation,
n facility values that align with checklist
implementation,
n how to build on past successes with patient
safety projects, and
n they must obtain multidisciplinary
involvement.
n Help ensure that perioperative team members
n understand the rationale for checklist
implementation,
n understand ongoing
patient safety efforts,
Resources for Surgical Checklist Implementation
n recognize their role in
Web sites
patient safety, and
n AORN Comprehensive Surgical Checklist. AORN, Inc. http://
n value multidisciplinary
www.aorn.org/Clinical_Practice/ToolKits/Correct_Site_Surgery_
involvement.
Tool_Kit/Comprehensive_checklist.aspx.
n Patient Safety Tool: SURPASS Checklist. Beckers Infection
and Quality Control. http://www.surpass-checklist.nl/dlChecklist
WRAP-UP
.jsf;jsessionid0FEB76A00DA444AA208CACA34C07F0E1?
The evidence supports surpageIdDownload&langen.
gical safety checklist use in
n WHO Surgical Safety Checklist Implementation Guide. World
the perioperative setting to
Health Organization. http://www.who.int/patientsafety/safesurgery/
help decrease the risk of a
checklist_implementation/en/.
patient safety event and to
n WHO Surgical Safety Checklist. World Health Organization
anticipate potential patient
(WHO). http://www.who.int/patientsafety/safesurgery/
issues postoperatively.6,8-13
checklist/en/.
The key is proper use and
Have team members introduce themselves before every procedure and ensure that everyone
in the room is introduced, including students.
Ensure that surgeons have an active role in the
checklist process by asking them to be leaders
of the process.
Ask all team members to stop and listen to the
surgeon or RN circulator who is conducting the
checklist and emphasize that all team members should agree on the information before
proceeding.
If any team member looks as if they are unsure,
ask questions to find out why.
Encourage surgeons to take five minutes at the
beginning of the day to go over the days
procedures with the other team members to
Videos
n Harvard team using the WHO Surgical Safety Checklist. Lifebox
Foundation. https://www.youtube.com/watch?vwgqIkhkXYMQ.
n How not to perform the WHO Safe Surgery Checklist.
WHOSurgeryChecklist. https://www.youtube.com/watch?
vDOGJMOMHDJk.
n WHO surgery saves lives checklist. WHOSurgeryChecklist.
https://www.youtube.com/watch?vCIFhLUiT8H0.
Web access verified June 11, 2014.
472 j AORN Journal
actually completing the

checklist steps. This Back
to Basics article provides
key strategies that can be
used to implement a checklist and some strategies for
success. Using these strategies will give perioperative
nurses, leaders, surgeons,
and other team members
the tools to successfully

implement a checklist that can help improve patient safety.
References
1. Gawande A. The Checklist Manifesto. New York, NY:
Metropolitan Books, Henry Holt and Company, LLC;
2009.
2. Safe Surgery Checklist. The Joint Commission. http://
www.jointcommission.org/safe_surgery_checklist/. Accessed June 11, 2014.
3. WHO Surgical Safety Checklist. World Health Organization. http://www.who.int/patientsafety/safesurgery/
checklist/en/. Accessed June 11, 2014.
4. Patient Safety Tool: SURPASS Checklist. Beckers Infection and Quality Control. http://www.surpass-check
list.nl/dlChecklist.jsf;jsessionid0FEB76A00DA444AA
208CACA34C07F0E1?pageIdDownload&langen.
Accessed June 11, 2014.
5. AORN Comprehensive Surgical Checklist. AORN, Inc.
http://www.aorn.org/Clinical_Practice/ToolKits/Correct_
Site_Surgery_Tool_Kit/Comprehensive_checklist.aspx.
Accessed June 11, 2014.
6. Borchard A, Schwappach DL, Barbir A, Bezzola P.
A systematic review of the effectiveness, compliance,
and critical factors for implementation of safety checklists in surgery. Ann Surg. 2012;256(6):925-933.
7. Glossary of terms. Relative risk. Agency for Healthcare
Research and Quality. http://effectivehealthcare.ahrq
www.aornjournal.org
8.
9.
10.
11.
12.
13.
.gov/index.cfm/glossary-of-terms/?pageactionshow
term&termid57. Accessed July 16, 2014.
Klei WA, Hoff RG, van Aarnhem EE, et al. Effects of
the introduction of the WHO Surgical Safety Checklist
on in-hospital mortality. Ann Surg. 2012;255(1):44-49.
Lubbeke A, Hovaguimian F, Wickboldt N, et al. Effectiveness of the Surgical Safety Checklist in a high standard care environment. Med Care. 2013;51(5):425-429.
Treadwell JR, Lucas S, Tsou AY. Surgical checklists:
a systematic review of impacts and implementation.
Br Med J. 2014;23(4):299-318.
Urbach D, Govindarajan A, Saskin R, Wilton A, Baxter N.
Introduction of surgical safety checklists in Ontario,
Canada. N Engl J Med. 2014;370(11):1029-1038.
Leape LL. The checklist conundrum. N Engl J Med.
2014;370(11):11.
Conley D, Singer S, Edmondson L, Berry W,
Gawande A. Effective surgical safety checklist implementation. J Am Coll Surg. 2011;212(5):873-879.
Lisa Spruce, DNP, RN, ACNS, ACNP, ANP,

CNOR, is the director, evidence-based perioperative practice, AORN, Inc, Denver, CO.
Dr Spruce has no declared affiliation that could
Check back in January 2015 for the next Back to Basics topic: Evidence-Based Practice.
AORN Journal j 473
Developing Strategies for

On-Call Staffing: A Working
Guideline for Safe Practices
JOHN OLMSTEAD, MBA, ADN, RN, CNOR, FACHE; DEBORAH FALCONE, RN; JACY LOPEZ, RN;
LINDA MISLAN, BSN, RN, CNOR; MARIALENA MURPHY, MSN, MSHA, RN, CNOR; TONI ACELLO, MSN, RN
ABSTRACT
Effective on-call clinical staffing is critical to providing perioperative services to
patients requiring emergency surgical care. Without careful monitoring of
continuous work hours and hours worked per week, staffing practices can
adversely affect the ability of personnel to function and provide care. Managers
and perioperative personnel must carefully evaluate their on-call schedule to
ensure the provision of safe medical care for their patients. Perioperative leaders
at two hospitals partnered to create a safety guideline for on-call staffing practices,
which includes zone guides for determining workload intensity. This guideline has
served to help managers evaluate the general safety of their staffing plan and
identify on-call practices that may need improvement or support in their areas of
responsibility. Key recommendations from the guideline can help perioperative
managers at other facilities establish clinical staffing plans and on-call practices
that are safe and effective. AORN J 100 (October 2014) 369-375. AORN, Inc,
2014. http://dx.doi.org/10.1016/j.aorn.2013.08.020
Key words: on-call practices, call staffing, safe staffing levels, on-call guidelines,
call shifts, extended work hours, off-shift schedules, continuous work hour practices,
call coverage, zone guide.
erioperative personnel have the unique

privilege of working hand in hand with
physicians during surgical and other invasive procedures. Experiences in the surgical setting
are what most patients recall as the most serious
moments of their life. Although health care providers from other disciplines also work with patients during critical times of care, the surgical
experience is unlike any other in the health care
setting because of the teamwork, environment, and
interpersonal dynamics. Regarding on-call staffing
practices in the surgical setting, physicians are

expected to respond day or night to emergencies
with their patients, as they do in other areas. Although nonperioperative nursing personnel are accustomed to a more traditional work schedule (ie,
nurses who are off the clock do not return to
the hospital except to pick up additional overtime
shifts), nurses who work in the perioperative
services area are required to cover off shifts
(ie, be on call) and accept the necessity of oncall coverage.
AORN, Inc, 2014
October 2014
Vol 100
No 4
AORN Journal j 369
October 2014 Vol 100
No 4
OLMSTEAD ET AL
Effective on-call staffing practices are vital to

hours and increased medical errors, a known safety
hospitals being able to provide safe surgical patient
issue.7,8
care. For example, on-call staffing is a workforce
In 2013, leaders from Community Hospital,
requirement in 24-hour hospital facilities offering
Munster, Indiana, and Scottsdale Healthcare
inpatient surgery,1 and adequate call coverage is an
Osborn Medical Center, Scottsdale, Arizona,
formed a partnership to create an On-Call Best
integral component of meeting regulatory safety
1
Practices Safety Guideline. The goal of this projrequirements. Although the importance of proect team was to create a working guideline for OR
viding on-call services is clearly understood by
leaders that, instead of setting standards, would
personnel, recommendations addressing safe
serve as a tool for
on-call practices are
managers in their
largely absent from
evaluation and prothe industry.2 Regula- Managers and perioperative personnel must
motion of the general
tory bodies, such
carefully evaluate their on-call schedule to
safety of their on-call
as the Centers for
ensure the provision of safe medical care for
staffing practices.
Medicare & Medicaid their patients.
Another goal for this
Services and state
guide was for it to
boards of health, do
provide managers with information to identify
not provide guidelines specific to on-call coverage.
areas or practices that may need improvement
Managers and perioperative personnel must careor support in their areas of responsibility.
fully evaluate their on-call schedule to ensure the
provision of safe medical care for their patients.
SETTING
This lack of regulatory guidance, however, is
Community Hospital is a 425-bed tertiary care
problematic because it permits managers at indimedical center located approximately 25 miles
vidual facilities to arrange whatever staffing plan
from downtown Chicago. The Surgical Services
and on-call practices they deem feasible for their
1
Department performs roughly 10,000 surgical and
varying community and perioperative needs.
5,000 gastrointestinal procedures annually, with a
Leaders from two facilities partnered to conduct
staff of approximately 160 full-time-equivalent
a literature search that produced little information
employees. In contrast, Scottsdale Healthcare
on this safety issue. Most literature addressing
Osborn Medical Center is a 337-bed, full-service
perioperative on-call staffing practices pertains to
Magnet hospital recognized as a leader in the
the quality-of-life aspect of on-call time.3-8 These
fields of trauma, orthopedics, neurosurgery, cararticles focus on improving employee satisfaction
diovascular surgery, and critical care. Personnel
and reducing unnecessary turnover linked to inin this level I perioperative department perform
trusive call schedules and provide ideas that can be
approximately 7,800 surgical procedures per year,
used to decrease the negative effects that call shifts
4,5
and the surgery department employs approximately
have on employees quality of life. Safety rec75 full-time-equivalent employees.
ommendations are sparse but focus on ensuring that
on-call practices meet minimum standards (eg,
minimum staffing standards of one RN and one
COMMON PROBLEMS
surgical technician per surgical procedure) to safely
Although 1,700 miles apart, the leadership teams
6
treat after-hours patients. The only pointed safety
from both Scottsdale Healthcare Osborn Medical
recommendations are those that identify the link
Center and Community Hospital faced a common
between long work hours and decreased safety,
problem. In arranging the on-call staffing schedule,
which supports the link between continuous work
managers struggled with the competing demands of
370 j AORN Journal
ON-CALL STAFFING STRATEGIES
www.aornjournal.org
patient safety and staff quality of life. The leaders

faced several common dilemmas:
n
How many on-call shifts are too many?

n When does the number of on-call hours worked
become unsafe?
n When personnel work call hours directly after a
regularly scheduled shift, at what point is patient safety compromised?
n How much recuperation time, if any, should a
hospital guarantee an employee between call
hours worked and the next regularly scheduled
shift?
ON-CALL TIME BY ZONE INTENSITY
Most employees will agree that they are affected by
stress during on-call hours, even when not actively
working the call hours. The responsibility of
responding to the hospital within the facilitys
specified time frame affects the employees living
situation (eg, sleep cycles, family or social time).
Although being on call does not always constitute
working a shift, on-call employees must alter their
time outside of work to stay within the accepted
travel distance of the hospital and must ensure that
they can be reached by telephone or page. For this

reason, the responsibility associated with being on
call places a burden not just on the staff member
but also on his or her family, creating additional
stress. The AORN guidance statement: safe oncall practices in perioperative practice settings
recommends monitoring how often employees are
asked to be on call.2
A compilation of the recommendations for
continuous work hour practices as received from
OR managers during interviews that members of
the project team conducted at Community Hospital
and at Scottsdale Healthcare Osborn Medical
Center are presented in Table 1. We categorized the
recommended staffing practices according to their
intensity by dividing them into the following zones:
n
Green Zone: Total hours worked are 0 to 48

hours per week, which is the equivalent of the
employee working one full workday beyond the
accepted full-time workweek value of 40 hours.
n Yellow Zone: Total hours worked are 49 to 55
employee working two full workdays beyond
the full-time value of 40 hours.
TABLE 1. Zone Guide for Determining Workload Intensity and Safe On-Call Practices
Green Zone (ie, usual
and customary practice)
Yellow Zone
(ie, unusual practice)
Red Zone (ie, very

unusual practice)
0e10
0e48
11e20
49e55
20
55
0e12
12e16
16
12
8e12
<8
Weekly
Biweekly
Monthly or less
Staffing time
Number of call shiftsa per month
Hours worked in a week (ie, regular work hours plus call hours)
Duration of continuous work
hours per day
Recuperative, off-duty hours between the last hour of a shift
worked and the start of the next
shift assigned
Frequency with which the on-call
employee performs the types
of procedures during regular
practice hours that they are
assigned to cover on call
a
Shift duration can vary but is generally 8 to 12 hours.
AORN Journal j 371

n
No 4
Red Zone: Total hours worked are 56 or more

employee working three or more full workdays
beyond the accepted, full-time work hours in
seven calendar days.
Most on-call staffing plans require employees to

adhere to on-call practices similar to those noted in
the Green Zone. Thus, in this zone, on-call time
affects one-third or fewer of employees off-hours
time in a month (eg, in a 30-day month, an employee would be on call 10 days or fewer). Most
managers set on-call staffing plans to guarantee that
personnel are available to provide perioperative
care; in doing so, however, they may not be ensuring
safe on-call practices. Instances can arise in which a
manager arranges on-call practices similar to those
described in the Yellow Zone, thereby affecting onethird to two-thirds of employees off-hours time,
or for practices similar to those described in the
Red Zone, affecting more than two-thirds of
employees off-hours time. Common on-call staffing
problems include employees who are required to work
n
more than 60 hours per week,

n more than 16 continuous hours,
n a regular shift with fewer than eight hours of
recuperation after having worked an on-call
shift, and
n an on-call shift for a procedure that they do not
have adequate experience performing.
Monitoring continuous work hours and on-call
hours can prevent these problems from occurring.
In addition, monitoring of staffing time helps prevent abusive on-call staffing practices.
Working More Than 60 Hours per Week
Numerous safety studies2-8 and regulations identify
working more than 60 hours in a seven-day period
as an issue for managerial concern.1 A 40-hour
workweek is generally accepted as an expectation
of full-time-equivalent employees; thus, a 60-hour
workweek is 50% above the 100% expectation.
372 j AORN Journal
OLMSTEAD ET AL
Although most employees can cite instances of
having worked more than 60 hours in seven consecutive days, managers should closely monitor
staffing situations in which employees are working
hours that place them in the Red Zone. All managers continuously monitor the schedules they
create. Arranging for staff member relief is ideal
but cannot be guaranteed; this guideline provides
managers facing this problem some support
when talking to administrators about needing
more personnel.
Working More Than 16 Continuous Work
Hours
Scheduling employees to work for more than 16
continuous hours is generally avoided except in the
instance of 12-hour shift employees who are on call
after their scheduled shifts.2 Depending on the
history and scheduling needs of the department,
limiting 12-hour shifts may not be possible. Thus, it
is important for managers to monitor continuous
work hours with specific concern for employees
whose hours frequently extend past 16 continuous
work hours. For example, working a 12-hour shift,
staying late to finish a procedure that has exceeded
its scheduled time, and then having a call shift to
cover can easily amount to a 16-hour day. Managers
should focus on reducing the routine occurrences
of 16 continuous work hours if possible. This is
difficult because managers have no way of knowing
whether an employee will work late on-call hours;
however, managers can try to send the employee
home early the next day but cannot guarantee it.
Being On Call and Covering Scheduled
Procedures Without Adequate Rest
The period between the employees last on-call
procedure and his or her next regularly scheduled
shift is the most difficult situation facing on-call
personnel because often employees do not get adequate recuperation. For example, a perioperative
nurse may be called in at midnight to cover an open
heart procedure that finishes at 5 AM and still be
scheduled to cover a full days work that begins at
www.aornjournal.org
during their on-call shift. Although this recom7 AM. Guaranteeing that the nurse has an eightmendation seems intuitively obvious, as instituhour recuperation interval between the last hour
tional finances become increasingly scrutinized,
workedd5 AM in this scenariodand the next
adequate staffing may not occur. Participating in
scheduled shift would necessitate cancelling the
on-call procedures requires personnel to have
7 AM procedure if no other staff member were
routine exposure to procedures in the specialty area
available to cover for the nurse. For this reason, no
that is likely to be seen during the assigned call
hospital guarantees an RN will be sent home the
shift, and managers should validate team member
day after a late night of on-call procedures. Because
competencies to ensure the same level of compeof critical patient care needs, the manager is faced
tency in on-call prowith balancing the
cedures as they do
safety of the employee
working with little or Providing a rest area for on-call team members for regularly schedno rest against delay- can help reduce fatigue; however, rest areas in uled procedures. For
example, an RN with
ing or cancelling the
hospitals are becoming increasingly rare and
scheduled patients
more difficult to acquire and maintain because competency in general
of budget and space constraints.
surgery who is assigned
surgery the next
on-call coverage for
morning. For this
open heart procedures
reason OR managers
may not have the required training. This lack of
should make every attempt to limit this situation
training could lead to an adverse clinical outcome
whenever possible. If the manager cannot guaror sentinel event during an after-hours emergent
antee adequate recuperation after an on-call shift,
situation.
he or she usually can arrange for the employee to
The matter of maintaining competency is diffibe relieved shortly after his or her next regularly
cult for managers to address. Managers must have
scheduled shift to prevent tired employees from
a process in place for determining how many open
having to complete their entire scheduled shift
heart procedures a team member must participate
and to ensure a safe working environment.
with to ensure continued competency. The folWhen a situation such as the preceding scenario
lowing scenario will help illuminate this problem.
arises, the manager should focus his or her efforts
A nurse who previously worked on the open
on relieving the nurse on duty as soon as possible to
heart surgery team for five years switched to a
limit the amount of time that the nurse is required
general surgery call team four years prior. The
to work without rest. Another managerial considnurse volunteers to pick up two holiday weekends
eration is providing a sleep room for team members
of open heart on-call time because her family will
who are on call and may have inadequate recube out of town. The question that arises, after four
peration time between their last call hour worked
years, is the nurse competent to cover an emergent
and their next scheduled work shift. Providing a
open heart surgery procedure? This question is
rest area for on-call team members can help reduce
practitioner specific; however, our interviews with
fatigue; however, rest areas in hospitals are bevarious perioperative directors indicated the folcoming increasingly rare and more difficult to aclowing levels of frequency in determining suitable
quire and maintain because of budget and space
competency of on-call personnel:
constraints.
Inexperienced On-Call Staff
On-call team members should have experience
routinely performing procedures that may occur
Green Zone: on-call assignments for procedures

in which the practitioner has weekly routine
experience. The nurse must have participated in
AORN Journal j 373
OLMSTEAD ET AL
No 4
open heart procedures at least weekly during

regular practice hours (ie, often).
n Yellow Zone: on-call assignments for procedures in which the practitioner has biweekly
routine experience. The nurse must have participated in open heart procedures at least
biweekly during regular practice hours (ie,
every now and then).
n Red Zone: on-call assignments for procedures
in which the practitioner does not have routine
experience. The nurse has participated in open
heart procedures during regular practice hours
less than biweekly (ie, rarely).
Scheduling assignments by zones may aid managers in making safe and effective decisions
regarding call coverage, such as assigning or not
assigning the call coverage of a specialty area to
team members who volunteer to cover the call time
but have not worked in the specialty in several years.
RECOMMENDATIONS
Based on the collaboration of this project team, we
suggest the following approach to staffing plans
and on-call practices to help ease the stress of
staffing and to provide safe care.
practices to ensure safety for patients, team members, physicians, the hospital, and, ultimately, the
community. Health care is experiencing tumultuous
change, and careful and consistent provision of safe
staffing and on-call practices are perhaps more
important now than ever before. As health care
reimbursement dollars are stretched thinner and
thinner, the struggle to provide a strong bottom line
along with a safe patient care environment will
force managers to scrutinize every aspect of staffing
for better efficiency and safety. In addition, the
recommendations shared in this article are meant to
provide a working model with which managers can
collaborate with senior leaders to provide highquality health care for their communities. Managers
who have ways to improve staffing plans and oncall practices are encouraged to e-mail us: John
Olmstead (jolmstead@comhs.org), Deborah Falcone
(dfalcone@comhs.org), Jacy Lopez (jlopez@comhs
.org), Linda Mislan (lmislan@comhs.org), Marialena
Murphy (murphy.marialena@mayo.edu), and
Toni Acello (acelloto@einstein.edu).
Editors note: Magnet is a trademark of the
American Nurses Credentialing Center, Silver
Spring, MD.
Monitor the number of calls that employees

take, with the planned target of 10 or fewer calls
per employee during a 30-day period.
n Monitor the history of the hours worked by
employees, with the planned target average of
48 hours or fewer per week per employee.
n Arrange a staffing and on-call communication
plan so that all efforts are made to
n avoid employees working 16 or more continuous work hours and
n enable employees to have eight or more hours
of recuperation between the last procedure
performed and the next scheduled shift.
n Assign call shifts only to those employees who
have documented training and routine experience in performing the on-call procedure.
These recommendations can serve as a reference
model for managers to use in their review of on-call
374 j AORN Journal
References
1. Surgical Services Section, Delivery of Service, Conditions
of Participation, Centers for Medicare & Medicaid Services.
CFR 482.51b. CMS.gov. http://www.cms.gov/Regulations
-and-Guidance/Guidance/Manuals/downloads/som107ap_
a_hospitals.pdf. Accessed July 17, 2014.
2. AORN guidance statement: safe on-call practices in perioperative practice settings. In: Perioperative Standards
and Recommended Practices. Denver, CO: AORN, Inc;
2014:611-613.
3. Oliver EL. Scheduling employees for weekend and on-call
work. AORN J. 1986;44(2):301-303.
4. Mathias J. Creative call plans help to keep OR staff. OR
Manager. 2003;19(3):25.
5. Mathias J. New on-call plan helps to stabilize the staff and
budget. OR Manager. 2013;29(4):14-15.
6. Mathias J. ORs modifying on-call practices to recruit and
retain nursing staff. OR Manager. 2013;29(4):1, 12-13.
7. Dexter F, ONeill L. Weekend operating room on call
staffing requirements. AORN J. 2001;74(5):664-665,
668-671.
8. Wysocki A. Revising the surgical registrar on-call roster.
ANZ J Surg. 2010;80(7-8):490-494.
John Olmstead, MBA, ADN, RN, CNOR,

FACHE, is director, Emergency and Surgical
Services, Community Hospital, Munster, IN.
Mr Olmstead has no declared affiliation that
could be perceived as posing a potential
article.
Deborah Falcone, RN, is the manager, Surgery
Department, Community Hospital, Munster,
IN. Ms Falcone has no declared affiliation
article.
Jacy Lopez, RN, is assistant manager, Surgery
IN. Ms Lopez has no declared affiliation that
could be perceived as posing a potential
article.
Linda Mislan, BSN, RN, CNOR, is clinical
educator and quality manager, Surgery
www.aornjournal.org

IN. Ms Mislan has no declared affiliation that
could be perceived as posing a potential conflict
of interest in the publication of this article.
Marialena Murphy, MSN, MSHA, RN, CNOR,
was a clinical director, Perioperative Services,
Scottsdale Healthcare Osborn Medical Center,
Scottsdale, AZ, at the time this article was
written, and is currently a nurse administrator for
Surgical Services at the Mayo Clinic, Phoenix,
AZ. Ms Murphy has no declared affiliation
article.
Toni Acello, MSN, RN, is a nurse manager,
Osborn Inpatient Operating Room, Scottsdale
Healthcare Osborn Medical Center, Scottsdale,
AZ. Ms Acello has no declared affiliation
article.
AORN Journal j 375
Hemostatic Agents: A Guide
to Safe Practice for
Perioperative Nurses
3.0
MARGARET A. CAMP, MSN, BSN, RN
www.aorn.org/CE
Approvals
indicates that continuing education (CE) contact hours

are available for this activity. Earn the CE contact hours by
completes this program can immediately print a certificate of
completion.
relicensure.
Event: #14527
Session: #0001
Fee: Members $24, Nonmembers $48
The CE contact hours for this article expire August 31, 2017.
Purpose/Goal
To provide the learner with knowledge specific to the effective
management of bleeding during operative and other invasive
procedures and the use of hemostatic agents to augment the
patients natural clotting abilities.
Objectives
1. Discuss why hemostasis is needed during operative and
other invasive procedures.
2. Describe the basic mechanisms that naturally occur to
promote hemostasis.
3. Discuss the clinical indications for the use of hemostatic
agents.

Having received money for the development of education
programs and for travel, accommodations, and meeting expenses from Ethicon, Margaret A. Camp, MSN, BSN, RN,
has declared an affiliation that could be perceived as posing
a potential conflict of interest in the publication of this
article.
by Rebecca Holm, MSN, RN, CNOR, and Helen Starbuck
Pashley, MA, BSN, CNOR, clinical editors, with consultation
from Susan Bakewell, MS, RN-BC, director, Perioperative
Education. Ms Holm, Ms Starbuck Pashley, and Ms Bakewell
have no declared affiliations that could be perceived as posing
potential conflicts of interest in the publication of this
article.

article.
Disclaimer
Accreditation
in the activity.
AORN, Inc, 2014
August 2014
Vol 100
No 2
AORN Journal j 131
Hemostatic Agents: A Guide

to Safe Practice for Perioperative
Nurses
3.0
MARGARET A. CAMP, MSN, BSN, RN
www.aorn.org/CE
ABSTRACT
Perioperative hemostasis, the effective management of bleeding during operative
and other invasive procedures, can involve the use of blood, blood products, and
hemostatic agents to augment the patients natural clotting abilities. Currently, more
than 50 hemostatic products are available in the marketplace and dozens more are in
development. It is important for perioperative nurses to understand each of the
hemostatic agent categories and their actions, properties, applications, and limitations. This article provides an overview of the normal coagulation process (ie,
clotting cascade) that is activated by the body when there is a bleeding episode; the
management of blood products and the rationale for reducing their use; the financial
implications of hemostatic agent use; and how these agents are used, their clinical
indications, and potential complications from their use. AORN J 100 (August 2014)
Key words: clotting cascade, bleeding, hemostasis, hemostatic agents.
ince ancient times, people have searched

for ways to effectively control bleeding,
especially when the bodys normal clotting
responses are insufficient to accomplish satisfactory hemostasis (ie, the reduction or stoppage of
blood flow). In early times, bandaging, pressure, or
crude forms of cautery applied to a wound had to
suffice until the idea of using thread to suture
wounds became common; eventually, barbers and
boxers discovered that thrombin could be used to
stop bleeding.1 As early as the 1940s, surgeons
were using thrombin in surgery to stop bleeding.1
The use of thrombin in surgery for hemostasis has
increased exponentially since then. In the past
decade, the emergence of commercially prepared

hemostatic agents has been unsurpassed. In todays
OR, surgeons have a broad range of products to
help control bleeding. Selecting the right product
for the right procedure and using it correctly has
increasingly become a challenge given the current
depth and breadth of products currently available in
the marketplace.
Effective management of bleeding during operative and other invasive procedures is a critical
factor in achieving optimal patient outcomes. It is
important for the perioperative nurse to understand
the clotting cascade, clinical indications for using
hemostatic agents, the types of hemostatic agents
132 j AORN Journal
August 2014
Vol 100 No 2
AORN, Inc, 2014
HEMOSTATIC AGENTS: A GUIDE TO SAFE PRACTICE

available and their actions, and the potential limitations or complications of these products. In addition, understanding the importance of blood and
blood product management is imperative.
Today, there is increased focus on cost containment because of changes in reimbursement to health
care providers as well as a growing elderly population in the United States with higher acuity levels
and greater use of medical and surgical services.2
These factors are some of the primary drivers that
push providers to look for more efficient and
effective ways to provide surgical care, less costly
alternatives to the traditional surgical procedures,
and ways to use products and supplies more effectively, including blood, blood products, and
other hemostatic agents.
In the United States, operative and other invasive procedures account for the transfusion of more
than 15 million units of packed red blood cells per
year.3 In addition to the knowledgeable use of hemostatic agents, health care providers are encouraged to reduce the use of blood and blood products
because of the evidence that limiting their use improves patient outcomes and reduces the incidence
of surgical site infections, costs, and a patients risk
of complications.4 In addition to these concerns and
reasons for reducing blood product usage, there are
also concerns that the supply of blood donors is
declining and the blood supply itself is diminishing
despite a heavy emphasis on blood conservation
measures.3
HEMOSTASIS
During any operative or invasive procedure, surgeons frequently need to achieve some level of
hemostasis. Although the need to control brisk
arterial bleeding is obvious, surgeons also need to
control oozing from small vessels. For example,
Spahn et al5 reported that 50% of trauma-related
deaths are the result of uncontrolled bleeding.
Generally, bleeding from an arterial source can be
controlled by mechanical means, such as direct
pressure with sponges or gauze or the application
of sutures, staples, or clips. Bleeding that is more
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difficult to control occurs when the patient experiences diffuse venous bleeding. This can result in
coagulopathy, which develops because the body is
unable to compensate for the rapid consumption
and dilution of platelets and coagulation factors
during an emergent bleeding episode.6 Therefore, it
is imperative to control bleeding and achieve hemostasis as quickly as possible to avoid the complications of coagulopathy. When a vessel is
damaged either by accident (eg, trauma) or by
intention (eg, surgical incision), basic mechanisms
occur naturally to promote hemostasis: vasoconstriction, the formation of a platelet plug, and
coagulation.7
Vasoconstriction
After vessel injury occurs, vasoconstriction is
the bodys first response to mechanically slow
bleeding. In the vasoconstriction phase, the body
attempts to slow the flow of blood by both local and
systemic mediators. At the local level, thromboxane is released to aid in vessel constriction. The
adrenal glands also release epinephrine, which acts
systemically to increase vasoconstriction and slow
bleeding.8 After vessel constriction, the body responds to quickly form a platelet plug. 7 This
platelet plug is temporary and unstable, and a fibrin
clot needs to form to provide lasting hemostasis.
Platelet Plug Formation
In this phase of hemostasis, circulating thrombin
causes the release of additional platelets that
initiate the formation of a loose platelet plug.
Fibrinogen, a component of the clotting mechanism
or cascade, is responsible for the clumping of
platelets, which adhere to collagen fibers and
release chemicals such as adenosine diphosphate.
The platelets also release other mediators (eg, serotonin, phospholipids, lipoproteins, other proteins)
that are important in the clotting cascade. The
platelet plug acts as a temporary measure to stem
the flow of blood in the injured vessel. Although
the platelet plug is important, its action is to seal
the tear rather than occlude the vessel lumen.3
AORN Journal j 133
CAMP
August 2014 Vol 100 No 2
Unfortunately, platelet plugs are not effective in

controlling hemorrhage from large vessels, and it is
then that the bodys coagulation mechanisms must
be activated to form a permanent fibrin clot.3
Coagulation
The third phase, coagulation, is a complex bodily
response that involves multiple factors and processes. Coagulation is the transformation of liquid
blood into a gelatin-like substance (ie, a clot).
Approximately a dozen clotting factors normally
exist as inactive proteins in the circulating blood.
An injury to a vessel causes these circulating proteins to be activated. The activation of these clotting factors is sequential in nature; when the first
factor is activated, it automatically causes subsequent factors to be activated in a very specific order.9 This process is known as the clotting cascade
and eventually a clot is formed, which seals the
injured vessel.
CLOTTING CASCADE
The clotting cascade is composed of intrinsic and
extrinsic pathways, and the key mediator of both
pathways is thrombin. Thrombin is derived from an
inactive substance called prothrombin. The clotting
cascade pathways, while triggered by two different
mechanisms, act synchronously. Both of these pathways are complex and merge to create what is
known as the common pathway of hemostasis, the
end product of which is the formation of a fibrin
clot.4 An illustration of the clotting cascade is
available in the article by Overbey et al10 that appears in this issue of AORN Journal.
Intrinsic Pathway
During normal blood flow, inactivated coagulation
proteins circulate in the blood. Under normal circumstances, blood flows briskly and moves these
proteins through the vessels. The lining of the blood
vessels (ie, the endothelium) does not contain
thrombogenic tissue factor or collagen, and it promotes blood flow rather than coagulation.4 The
intrinsic pathway to activate the clotting factors in
134 j AORN Journal
the blood is not initiated from a vessel injury and

can be triggered by blood stasis (eg, deep vein
thrombosis, thromboembolism). When the intrinsic
pathway is activated, it triggers activation of factors
XIIa, XIa, IXa, and Xa in combination with calcium in the blood to initiate coagulation.
Extrinsic Pathway
Damage outside a vessel wall also can activate
a cascade of clotting factors. When the vessels
subendothelial connective tissues are exposed to
the escaping blood, they stimulate the activation of
tissue thromboplastin, which causes factor X to be
activated. It is at this point that both the intrinsic
and extrinsic factors converge into the common
pathway. Whenever either pathway is initiated,
the basic response is the exposure of platelets to
collagen, which causes an initial clot to form. It is
important to note that the clotting cascade begins
sooner when the extrinsic pathway is initiated because it bypasses some of the steps required for the
intrinsic pathway process to occur.4
Common Pathway
The common pathway of the coagulation cascade
occurs when the intrinsic and extrinsic pathways of
coagulation meet through activation of factor X.
Activated factor X in combination with platelets,
factor V, and calcium convert prothrombin to
thrombin. The role of thrombin in the coagulation
cascade includes the activation of
n
fibrinogen to form a fibrin clot;

n factor XIII to stabilize the clot;
n platelets to assist in sealing the clot; and
n factors V, VII, and XI, which are needed to
stimulate the production of more thrombin
molecules.
This is essential for fibrin strands to form a mesh
and subsequently form a hemostatic plug.4
There are many factors involved in the clotting
cascade (Table 1). Of these elements, one of the
key factors in achieving hemostasis through both
normal body responses and surgical intervention
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TABLE 1. Factors Involved in the Clotting Cascade

Fibrinogen
n
n
Prothrombin
n
n
Vitamin K
Calcium
Factor X
Factors XI, XII, XIII
Factor V
Thrombin
Fibrin
Platelets
n
n
n
n
n
n
n
n
n
Intrinsic factors
Extrinsic factors
Common factors
Converted to brin by brinogen

Forms the clot
Converted to thrombin by factor X
Once activated, converts brinogen to brin
Required to synthesize brinogen to brin
Promotes platelet aggregation in combination with factors VII, X, XII, and XIII
Combined with other clotting factors converts prothrombin to thrombin
Acts to catalyze other factors in the coagulation process
Another element needed to convert prothrombin to thrombin
Converts brinogen to brin
Initially forms a loose mesh; in combination with factor XIII facilitates formation of dense ber mesh
Initially stick to vessel collagen to form a loose plug
Part of the foundation of the brin clot along with red blood cells
When an internal vessel injury occurs, factors XIIa, IXa, VIIa, and Xa are activated
When an external vessel injury occurs and the endothelium is disrupted, factors VIIa and X are
activated in combination with calcium and membrane phospholipids
The point where the intrinsic and extrinsic pathways merge or converge through activation of factor X
Subsequently, other elementsdincluding factor V and calcium in combination with plateletsdconvert
prothrombin to thrombin, which causes brinogen to form the brin clot
(ie, use of commercially prepared hemostatic

agents) is thrombin. Thrombin is the key enzyme in
blood coagulation. It is a sodium-activated protease
and is one of the bodys inherent defense mechanisms. Thrombin was one of the earliest enzymes
identified as a hemostatic agent and was a precursor
to many other vitamin K proteases, such as factors
VIIa, IXa, and Xa, which are critical for the convergence of the intrinsic and extrinsic pathways in
the coagulation cascade.11 Thrombin, whether in its
natural form in the body or as part of a commercially prepared product, has two distinct but opposing functions. It acts to support coagulation
when it converts fibrinogen to a fibrin clot that
holds the platelets in place at the bleed site and
starts the healing process. Conversely, thrombin
acts as an anticoagulant when it activates protein
C.9 For example, when there is no vascular disruption, thrombin improves circulation through its
anticoagulant action.1
TRADITIONAL HEMOSTATIC METHODS
There are three traditional hemostatic methods.
These include mechanical hemostasis via direct
pressure (eg, manual pressure, pressure dressings)

or mechanical products (eg, ligatures [ie, sutures],
staples, clips, clamps), thermal-based energy (eg,
monopolar, bipolar, ultrasonic, laser, argon vessel
sealing), and chemical agents (eg, epinephrine,
vitamin K, protamine, vasopressors).
Mechanical Hemostasis
The most common mechanical approach to control
bleeding is the application of direct pressure to the
bleeding site. Direct pressure is always the first
choice when there is a need to control bleeding; it
is the easiest, simplest, and most cost-effective
method of hemostasis. Direct pressure can be
applied manually or with pressure dressings.
Other mechanical hemostasis methods, such as
sutures, staples, and vascular clips or clamps, also
can be used. Sutures, clips, or ligatures offer a
reasonably easy and cost-effective method to control bleeding; however, the practitioner needs to
understand that the physical configuration of the
product being used may have different reactions in
the patients body. Some other considerations when
choosing a product are ease of use (ie, how easy the
AORN Journal j 135
CAMP
item is to handle) and whether the product will

achieve the desired hemostasis over time. Staples
and clips, which are foreign bodies, increase the
possibility of a foreign body reaction or improper
placement. Another factor to consider is the site of
the bleeding. Although arterial bleeding is more
challenging to control given the volume of blood
involved, arteries are generally easier to control
than diffuse capillary bleeding because of their size
and accessibility. Diffuse capillary bleeding often
involves large, hard-to-reach areas, especially in
minimally invasive procedures. Unfortunately,
mechanical methods are not always practical or
effective, depending on the severity and location of
the bleeding; in addition, although effective for
most bleeding, none of the mechanical methods
may be effective if the patient has a coagulopathy
or has been on anticoagulant medication.12
Thermal-Based Energy
In addition to pressure or other mechanical methods
of hemostasis, surgeons often use thermal energy to
achieve hemostasis. Although the most common
thermal energy application is monopolar electrosurgery, other thermal adjuncts include bipolar
cautery, lasers, vessel sealing devices, ultrasonic
waves, and argon-enhanced coagulation. Generally,
these methods are cost-effective; however, these
approaches may be ineffective on specific bleeding
sites, such as bone, friable tissue, or areas with
diffuse capillary bleeding.3,4 Energy-based hemostasis also carries the potential risk of destroying
healthy tissue and causing burns to adjacent tissue
because of stray currents.3
normal body coagulation mechanisms if they are

not administered correctly.4
TOPICAL HEMOSTATIC AGENTS

When traditional hemostatic methods (eg, mechanical, thermal, chemical) fail to achieve hemostasis, a wide variety of topical hemostatic agents
are available for use. The ideal hemostatic agent
requires ease of use, but it also must be safe, effective, and cost-effective and have US Food and
Drug Administration (FDA) approval. From a
safety perspective, the products need to be free
of infectious diseases and carcinogens, and they
should not have the potential to create immune
reactions in the patient.2
The products must work for the clinical indication for which they are approved, and the surgeon
must use the products according to the clinical
needs of the patient. For instance, using a hemostatic agent as a first response to a bleeding situation may not be ideal if other commonly used
measures (eg, pressure, sutures, thermal energy)
have not been tried. The products must also be easy
to access, prepare, and use. When there is significant bleeding, it is important that the RN circulator
can deliver the sterile product to the field efficiently. For a product to be cost-effective involves
both its acquisition cost and the amount of product
needed to achieve hemostasis. The RN circulator
can help by selecting the correct size of the product needed.
Generally, topical hemostatic agents are assigned
to one of five major groups:
n
Chemical Agents
The use of chemical agents is a third method that
surgeons often use for achieving hemostasis. These
agents include epinephrine, vitamin K, protamine,
and vasopressors. Although they are sometimes
effective, the disadvantages of using these products
are their potential effects on the natural clotting
cascade. Although the role of chemical agents is to
enhance hemostasis, they can negatively affect the
136 j AORN Journal
passive (ie, mechanical) agents (eg, oxidized

regenerated cellulose, beeswax),
n active agents (eg, bovine thrombin, pooled
human thrombin, recombinant thrombin),
n flowables (eg, bovine gelatin particles, human
thrombin, porcine gelatin particles with or without pooled human or recombinant thrombin),
n fibrin sealants (eg, human plasma-derived fibrin
sealants, the patients own plasma combined
with bovine collagen and thrombin, the patients

own plasma used to create fibrinogen and
thrombin), and
n adhesives (eg, skin sealants, synthetic tissue
sealants, glutaraldehydes, polyethylene glycol
polymers).
All of the products have unique properties, applications, and safety considerations. For example,
fibrin sealants require the presences of fibrin to be
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effective. Adhesives also provide hemostasis but

have different properties and applications than
other hemostatic agents and do not require a blood
component to be present for activation.3,13 Because
hemostatic agents act in different phases of the
coagulation cascade, it is important for the perioperative nurse, as the patients advocate, to be
knowledgeable about the products he or she is
delivering to the surgeon. Table 2 provides a broad
TABLE 2. Commercially Prepared Hemostatic Agents

Category
Passive (ie, mechanical)
Type
Porcine gelatin
Commercial name
n
n
Bovine collagen
n
n
n
n
Oxidized regenerated cellulose
n
n
n
Polysaccharide spheres
Beeswax, parafn, isopropyl palmate
n
n
n
n
Active
Flowable
Fibrin sealant
Bovine thrombin
Pooled human thrombin
Recombinant thrombin
Bovine gelatin and pooled human thrombin
Bovine gelatin (and/or thrombin)
Pooled human plasma
n
n
n
n
n
n
n
Adhesives
Patients own plasma and bovine thrombin

Patients own plasma
Polyethylene glycol hydrogels (PEG)
PEG trilysine amine
PEG human serum albumin
Liquid monomers
n
n
n
n
n
n
n
n
Synthetic tissue sealants

Glutaraldehyde cross-linked with bovine albumin
n
n
GELFOAM
SURGIFOAM powder and sponge
AviteneTM
Helistat
INSTAT
UltrafoamTM
SURGICEL
SURGICEL FIBRILLARTM
SURGICEL NU-KNIT
SURGICEL SNoWTM
AristaTM
Vitasure
Bone wax
Thrombin-JMI
EVITHROM
Recothrom
FLOSEAL
SURGIFLO
EVICEL
TISSEELTM
VitagelTM
CryoSeal
CoSealTM
DuraSealTM
Progel
DERMABOND
LiquiBand
SurgiSeal
OMNEXTM
BioGlue
GELFOAM and FLOSEAL are registered trademarks and TISSEEL and CoSeal are trademarks of Baxter Corporation, Deereld, IL. SURGIFOAM, INSTAT,
SURGICEL, SURGICEL NU-KNIT, EVITHROM, SURGIFLO, EVICEL, and DERMABOND are registered trademarks and SURGICEL FIBRILLAR, SURGICEL
SNoW, and OMNEX are trademarks of Ethicon, Johnson & Johnson, Inc, Somerville, NJ. Avitene and Ultrafoam are trademarks of Davol/Bard Company,
Warwick, RI. Helistat is a registered trademark of Integra Life Sciences Corporation, Plainsboro, NJ. Arista is a trademark of Medafor, Minneapolis, MN.
Vitasure is a registered trademark of Orthovita, Malvern, PA. Thrombin-JMI is a registered trademark of Pzer, New York, NY. Recothrom is a registered
trademark of The Medicines Company, Parsippany, NJ. Vitagel is a trademark of Stryker, Malvern, PA. CryoSeal is a registered trademark of ThermoGenesis
Corporation, Rancho Cordova, CA. DuraSeal is a trademark of Covidien, Boulder, CO. Progel is a registered trademark of NeoMend, Irvine, CA. LiquiBand is
a registered trademark of Cardinal Health, Dublin, OH. SurgiSeal is a registered trademark of Adhezion Biomedical, Wyomissing, PA. BioGlue is a registered
trademark of CryoLife, Kennesaw, GA.
AORN Journal j 137
CAMP
overview (but is not an all-inclusive list) of many

of the products in these groups. The important
information for the perioperative nurse is which
products fall into which category.
Passive Hemostatic Agents
Passive hemostatic agents also are referred to as
mechanical agents (Table 3). Although they are
relatively inexpensive, easy to prepare, and have no
special storage requirements, most of these products should not be used in confined areas of the
body where swelling would cause problems. They
are effective for areas of minimal bleeding, so they
generally are not effective for diffuse capillary or
brisk arterial bleeding. They require the presence of
blood for activation and do not affect or interrupt
the clotting cascade. Passive hemostatic agents
have been used since the 1940s and were the first
generation of commercially prepared hemostatic agents.14
Active Hemostatic Agents
Active hemostatic agents (Table 4) provide hemostasis within 10 minutes and control bleeding better
than passive agents alone.4 Currently, there are three
available active agents that are based on thrombin
(ie, pooled human thrombin, bovine thrombin, recombinant thrombin). Their function is to provide a
concentrated thrombin that is capable of converting
fibrinogen to a fibrin clot, which provides a framework for platelet aggregation and thrombus formation at the site of the injury.9 The rate of clot
formation is directly proportional to the concentration of thrombin. Although there are products with
TABLE 3. Passive (ie, Mechanical) Hemostatic Agents

Indication
Composition/origin
Minimal
bleeding
Porcine gelatin
Clinical considerations
n
n
n
n
Minimal
bleeding
Bovine collagen
n
n
n
n
n
n
Minimal
bleeding
Oxidized regenerated
cellulose
n
n
n
n
n
n
Minimal
bleeding
Polysaccharide
spheres
Minimal
bleeding
Beeswax, parafn,
isopropyl palmate
n
n
n
n
n
n
n
Do not inject
Do not use in the presence of infection
Risk of swelling
Risk of granuloma/abscess formation
Do not inject
Do not use in the presence of infection
Risk of swelling
Risk of granuloma/abscess formation
May contribute to adhesion formation
Sticks to the surgeons gloves and instruments
Do not inject
Broad indications for use
Bactericidal
Nonhuman/animal source
No preparation needed
Multiple thicknesses
Do not inject
Nonhuman/animal source
No preparation needed
Do not inject
Limited resorption
Inhibits bone regeneration
Increases infection risk
Commercial name
n
n
GELFOAM
SURGIFOAM powders
and sponges
AviteneTM sponge and

powder
Helistat
Helitene
INSTAT
UltrafoamTM
SURGICEL
SURGICEL FIBRILLARTM
SURGICEL NU-KNIT
SURGICEL SNoWTM
AristaTM
Bone wax
n
n
n
n
n
n
n
n
GELFOAM is a registered trademark of Baxter Corporation, Deereld, IL. SURGIFOAM, INSTAT, SURGICEL, and SURGICEL NU-KNIT are registered
trademarks and SURGICEL FIBRILLAR and SURGICEL SNoW are trademarks of Ethicon, Johnson & Johnson, Inc, Somerville, NJ. Avitene and Ultrafoam
are trademarks of Davol/Bard Company, Warwick, RI. Helistat is a registered trademark of Integra Life Sciences Corporation, Plainsboro, NJ. Helitene is a
registered trademark of Colla-Tec, Inc, Plainsboro, NJ. Arista is a trademark of Medafor, Minneapolis, MN.
138 j AORN Journal
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TABLE 4. Active Hemostatic Agents

Indication
Composition/origin
Localized and
Bovine thrombin
diffuse bleeding
n
n
n
n
n
Localized and
Pooled human thrombin
diffuse bleeding
n
n
n
Localized and
Recombinant thrombin
diffuse bleeding
n
n
Commercial name
Broad indications for use

Thrombin-JMI
Should not be used in patients with bovine allergies
Can stimulate antigen formation and interrupt the
clotting cascade
Has potential for infection transmission
Has a black box warning
Risk of swelling
EVITHROM
Do not use in patients with allergies to human
blood products
Unknown potential for infection transmission and
interruption of the clotting cascade
Recothrom
Commercially manufactured
Clinical studies to date have not demonstrated that
this product produces antigens or affects the
clotting cascade
Thrombin-JMI is a registered trademark of Pzer, New York, NY. EVITHROM is a registered trademark of Ethicon, Johnson & Johnson, Inc, Somerville, NJ.
Recothrom is a registered trademark of The Medicines Company, Parsippany, NJ.
lower thrombin concentrations that claim to be as

effective as those with higher concentrations (1,000
IU/mL), this should be a consideration in product
selection because higher concentrations yield better
hemostasis (ie, the speed with which thrombin clots
the blood depends on the concentration).3
Safety is a major consideration for thrombin
products, because thrombin acts at the end of the
clotting cascade and its interaction is negatively
affected by coagulopathies, such as clotting factor
deficiencies or platelet malfunction. These agents
are logical choices for patients receiving antiplatelet
or anticoagulant medications. Thrombin also has
several other functions within the body. It can
cause smooth muscle to constrict, activate platelets,
and aggregate platelets at an injury site. It attracts
neutrophils and fibroblasts and induces the formation of new cells for tissue and vascular repair and
remodeling.1
Bovine and recombinant thrombin products are
provided at room temperature but must be reconstituted with saline. Human pooled thrombin comes
fully mixed but frozen and requires thawing before
use; after thawing, it can be stored in a refrigerator
for up to 30 days. The surgeon can apply all of the
active hemostatic products directly to bleeding

surfaces or by using a spray applicator. These
products can be used alone or in combination with
an absorbable gelatin sponge or powder. There are
commercially manufactured kits that do not require
refrigeration and contain a porcine gelatin combined with a lyophilized human pooled thrombin.
The cost of these products is intermediate and
varies by manufacturer.
Perioperative nurses should understand what
happens at the vascular interface when thrombin is
being used and how this determines the efficacy of
the product. The amount of thrombin in the wound
can be affected or inhibited by factors such as hemodilution, absorptive sponges, wound irrigation,
or continuous wiping or blotting. Inhibitors such
as antithrombolytic hormone also can affect the
amount of thrombin in the wound by trapping
thrombin within the clot as the clot forms. The most
effective hemostasis occurs when the thrombin
mixes freely with the blood as soon as it reaches the
surface of the vessel injury.4
It is also important to understand that all thrombins are not created equal. Perioperative nurses need
to understand how the products work and their
AORN Journal j 139
reaction in the body both locally and systemically.

Because thrombin is a component in several of the
other hemostatic agents, this is important for perioperative nurses to understand when providing
hemostatic agents during an operative or other
invasive procedure.
Thrombin is a powerful product that is effective
in controlling both arterial and capillary bleeding. It
is important to discuss what alternative products
might be used that are safer and why. The perioperative nurse must be familiar with the thrombinbased products used, know their origin, and
understand the patient implications. The perioperative nurse has a responsibility to help team
members determine the appropriate product selection based on the patients history. Team members
should discuss all pertinent patient information
before the procedure. The nurse should know
whether the patient
n
n
n
n
n
has a history of allergies or reactions to any

hemostatic agents or a history of allergies to
bovine or porcine products,
has a religious or dietary reason for avoiding
hemostatic agents,
uses anticoagulant or antiplatelet medications
(eg, aspirin, other nonsteroidal antiinflammatory medications) or herbal supplements (eg, vitamin E, bilberry, Ginkgo, garlic,
cayenne) that might affect clotting mechanisms,
has a family history of bleeding disorders (eg,
hemophilia, sickle cell anemia), or
is anemic.
It is important for the nurse to assess the patient for

bleeding gums, easy bruising, excessive superficial
bleeds, or severe nosebleeds. The nurse also should
know whether the patient has a history of renal or
hepatic disease because both the kidneys and liver
secrete hormones that affect clotting mechanisms.
If these organs are not functioning correctly, this
can impede the coagulation process.
In addition, the nurse should understand what the
proposed procedure is; the patients potential for
bleeding; and the results of the patients coagulation
140 j AORN Journal
CAMP
profile, blood type, and cross-match. A signed consent for administration of blood or blood products
or a signed refusal should be verified and, if appropriate and consent for blood has been given, the
nurse should verify that there is autologous blood
product available and determine whether the donation has been verified. He or she should ascertain
whether there are plans for perioperative blood
salvage; if the patient is aware of this; and whether
the patient has any cultural, ethnic, or religious considerations for administration of blood or blood
products. This all should be discussed with the surgical team before the patient is brought to the OR.
Flowable Hemostatic Agents and Flowable
Products
Flowable hemostatic agents (Table 5) have both an
active and a passive component. The action of these
agents is to block blood flow and convert fibrinogen
to fibrin at the bleeding site. The passive component of these agents is a bovine or porcine gelatin
matrix; thrombin may be included as a component
or may be added as an individual item. These agents
produce a pasty substance that can be introduced
directly on a bleeding area, such as the liver or
kidney. These products are commonly used in spine
surgery; the surgeon lays the agent along the gutters
of the spine to reduce bleeding.1
Flowable products are composite hemostatic
agents that use microfibrillar collagen to facilitate
tissue healing and achieve hemostasis. Microfibrillar collagen is derived from bovine or porcine
sources and requires a wet field to be effective,
because the presence of blood has mechanical
properties that slow or obstruct the flow of blood
and thrombin to facilitate the conversion of fibrinogen into fibrin. These products conform easily to
the topography of the bleeding area and are easy to
apply. Flowable products require reconstitution,
and their cost is generally higher than that of mechanical or active products. The safety consideration with these products is that their swelling
properties require the surgeon to remove all excess
product after hemostasis is achieved.2
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TABLE 5. Flowable Hemostatic Agents

Indication
Localized
bleeding
Composition/origin
Bovine gelatin particles and
human thrombin
n
n
n
n
n
n
Localized
bleeding
Porcine gelatin particles

with or without thrombin
n
n
n
n
n
n
n
Commercial name
Should not be used in patients with bovine allergies FLOSEAL

Risk of swelling
Is approved for use in all specialties except
ophthalmology
Cannot be used with blood salvage devices or
cardiopulmonary bypass equipment
Absorbs in 6 to 8 weeks
Can be used in combination with Recothrom
SURGIFLO
Should not be used in patients with porcine allergies
Risk of swelling
Has potential for infection transmission when
human thrombin is used
Is approved for use in all specialties except
ophthalmology
Cannot be used with blood salvage devices or
cardiopulmonary bypass equipment
Absorbs in 4 to 6 weeks
FLOSEAL is a registered trademark of Baxter Corporation, Deereld, IL. Recothrom is a registered trademark of The Medicines Company, Parsippany, NJ.
SURGIFLO is a registered trademark of Ethicon, Johnson &Johnson, Inc, Somerville, NJ.
Fibrin Sealants
Fibrin sealants (Table 6) come in three types: fibrin
sealants, polyethylene glycol (PEG) polymers, and
albumin with glutaraldehyde. These products form
a barrier that is impervious to most liquids. Generally, sealants contain both fibrinogen and thrombin.
When the concentrated fibrinogen and thrombin are
mixed together, they create a fibrin clot that works
by increasing the rate of blood clot formation at the
injury site. The product consistency is a thin liquid
that can be applied as an aerosol spray. Generally,
surgeons use these products in combination with a
flowable agent. These are powerful, unique products
and have separate FDA approval as hemostats, sealants, and adhesives that are indicated for bleeding
control in surgical patients.2
Challenges with these products include reconstitution that may require a trained technician; when
using the patients blood to reconstitute the product,
often the concentration of fibrinogen may be low in
the patients own blood (eg, fibrinogen concentrations determine the strength of the clot). There is a
learning curve for surgeons who use these products,

and clinical concerns include blood-related reactions
(eg, antibody formation as pooled human thrombin is
a major component).4
One product classified in this category, ArtissTM,
is not a hemostatic agent. The most common clinical application for this product is to use it to adhere
autologous skin grafts to surgically prepared wound
beds in both children and adults with burns. The
cost is similar to that of other sealants. This product
is gas activated and frozen, and it must be thawed.
The product can be used up to 14 days after thawing
at room temperature. This product is not indicated as
an adjunct to other hemostatic agents because it
mimics the last stage of the coagulation cascade.15
TachoSil is an absorbable fibrin sealant patch.
This product controls local, diffuse bleeding but
does not control vigorous bleeding. It can be used as
an adjunct to flowables and in patients with coagulopathies or insufficient fibrinogen as well as for skin
grafts, dural sealing, bone repairs, splenic injuries,
colostomies, and reoperative cardiac surgeries.4
AORN Journal j 141
CAMP
TABLE 6. Fibrin Sealants

Indication
Composition/origin
Localized and
diffuse bleeding
Human plasmaederived
brin sealant
n
n
n
n
n
Localized and
diffuse bleeding
Patients own plasma

with bovine collagen
and thrombin
n
n
Localized and
diffuse bleeding
Patients own plasma to

create brinogen and
thrombin
n
n
n
n
Contains pooled human plasma

brinogen and thrombin
Does not need active blood or bleeding;
has derived brinogen for activation
Should not be used with blood salvage
devices or cardiopulmonary bypass
equipment
Has risks of air embolus, tissue rupture,
and gas entrapment
Should not be used in patients with
bovine allergies
Has potential for swelling, infection
transmission, foreign body reaction,
and immunologic and coagulation risks
Is approved for use in all specialties
except ophthalmology and
neurosurgery
Requires a trained technician for
processing
Should not be used in patients with
acquired or hereditary hematologic or
coagulation disorders
May not be used for patients on active
anticoagulants or nonsteroidal agents
Clinical studies indicate less effective
clot stability than commercially prepared products
Commercial name
n
TISSEELTM
EVICEL
VitagelTM
CryoSeal
TISSEEL is a trademark of Baxter Corporation, Deereld, IL. EVICEL is a registered trademark of Ethicon, Johnson & Johnson, Inc, Somerville, NJ. Vitagel is a
trademark of Stryker, Malvern, PA. CryoSeal is a registered trademark of ThermoGenesis Corporation, Rancho Cordova, CA.
Adhesives
Typically, the commercial products approved as
adhesives (ie, synthetic sealants) are divided into
four classes (Table 7):
n
cyanoacrylates,
synthetic skin sealants and tissue sealants,
n glutaraldehydes, and
n PEG polymers.
n
They vary in strength and surgical applications; however, each product basically glues tissue together. The
adhesive products have a variety of clinical applications and continue to evolve. The products contain
minimal amounts of thrombin but have other components that require careful consideration given
142 j AORN Journal
their chemical interactions and effect on body tissues. For instance, they cannot be used
n
in high tension areas such as joints because they

will not seal as desired or
n on infected or gangrenous tissue, decubiti, or
poorly healing wounds because they contain
formaldehyde.2
CONCLUSION
This article has not covered all products currently
available or all of the potential complications or
untoward events that may occur when using hemostatic agents. Hemostatic agents are powerful
tools in todays perioperative setting. They allow
n
n
Class
Indication
Cyanoacrylates
Synthetic skin
sealants
Localized
applications
Composition/origin
Liquid monomers
n
n
n
Synthetic tissue
sealants
Localized
applications
Monomers form polymers to create

a synthetic tissue sealant
n
n
n
n
Glutaraldehydes
Localized
applications
Glutaraldehyde linked with bovine

albumin
n
n
n
n
n
Polyethylene glycol
(PEG) polymers
Localized
applications
Polyethylene glycol hydrogels that

mix and cross-link at the wound site
n
n
n
n
n
n
PEG polymers
Localized
applications
PEG polymer and human serum

albumin combine to form a gel
n
n
n
n
n
PEG polymers
PEG polymer and a human blood product
n
n
n
n
DERMABOND
SurgiSeal
LiquiBand
OMNEXTM
BioGlue
CoSealTM
DuraSealTM
Progel
DERMABOND is a registered trademark and OMNEX is a trademark of Ethicon, Johnson & Johnson, Inc, Somerville, NJ. SurgiSeal is a registered trademark of Adhezion Biomedical, Wyomissing, PA. LiquiBand is a
registered trademark of Cardinal Health, Dublin, OH. BioGlue is a registered trademark of CryoLife, Kennesaw, GA. CoSeal is a trademark of Baxter Corporation, Deereld, IL. DuraSeal is a trademark of Covidien,
Boulder, CO. Progel is a registered trademark of NeoMend, Irvine, CA.
www.aornjournal.org
AORN Journal j 143
Localized
applications
Do not inject
Used as a replacement for sutures, primarily on facial,
extremity, and torso wounds
Attains the strength of healed tissue after 7 days
Do not inject
Used as an adjunct for vascular reconstruction
Mechanically seals a suture or graft line
Does not replace sutures, staples, or mechanical closure
Do not inject
Commonly used in vascular procedures for sealing
holes around staple lines
Good agent for arterial bleeding
Hypersensitivity is a concern
Is never absorbed and cannot be reapplied to the same
area in the future
Do not inject
Can prevent pericardial adhesions
Good for vascular reconstructions
Noninammatory
Infection rates are minimal
Should not be used in closed spaces because of product
swelling risk
Do not inject
Aid to prevent cerebrospinal uid leak
Seal dural incisions
Sprayed on
Contains blue dye for easier identication
Do not inject
Seals air leaks on lung tissues after the tissue has been
sutured or stapled
Commercial name
TABLE 7. Adhesives (ie, Synthetic Sealants)
CAMP
surgeons to control bleeding during operative and

other invasive procedures and minimize the need
for blood replacement. These products enhance the
view of the surgical field, avoid damage to major
fragile organs, and can shorten procedure times.
They are, however, products that need to be used
appropriately. The perioperative nurse needs to be
knowledgeable about the use of hemostatic agents;
understand what class the agent being requested
falls into; and whether the agent is FDA approved,
clinically cost-effective, and the most appropriate
product for the current situation. This requires
vigilance and knowledge on the part of the perioperative nurse to help ensure that the patient is
receiving care in a safe environment.
5.
6.
7.
8.
9.
10.
11.
12.
Editors notes: Artiss is a trademark and TachoSil

is a registered trademark of Baxter Corporation,
Deerfield, IL.
AORN does not endorse any commercial companys products or services. Although any commercial products that may be referenced in this
material are expected to conform to professional
medical/nursing standards, inclusion of this material does not constitute a guarantee or endorsement
by AORN of the quality or value of such product or
of the claims made by its manufacturer.
References
1. Lew W, Weaver F. Clinical use of topical thrombin as a
surgical hemostat. Biologics. 2008;2(4):593-599.
2. Spotnitz W, Burks S. Hemostats, sealants and adhesives:
components of the surgical toolbox. Transfusion. 2008;
48(7):1502-1516.
3. St Peter E, Kneedler J. Hemostasis [AORN Independent
Study Guide]. Presented at: AORN Congress; March 2-7,
2013; San Diego, CA.
4. Moss R. Management of Surgical Hemostasis: An Independent Study Guide. Denver, CO: AORN, Inc; 2013.
144 j AORN Journal
13.
14.
15.
http://www.aorn.org/search.aspx?searchtextManagement
%20of%20Surgical%20Hemostasis:%20An%20Indepe
ndent. Accessed February 26, 2014.
Spahn DR, Bouillon B, Cerny V, et al. Management of
bleeding and coagulopathy following major trauma: an
updated European guideline. Crit Care. 2013;17(R76):
1-53.
Bollinger D, Gorlinger K, Tanaka K. Pathophysiology
and treatment of coagulopathy in massive hemorrhage
and hemodilution. Anesthesiology. 2010;113(5):1-26.
Samudrala S. Topical hemostatic agents in surgery: a
surgeons perspective. AORN J. 2008;88(3):S2-S11.
Kaur P, Basu S, Kaur G, Kaur R. Transfusion protocol
in trauma. J Emerg Trauma Shock. 2011;4(1):103-108.
Ham SW, Lew WK, Weaver FA. Thrombin use in surgery: an evidence-based review of clinical use. J Blood
Med. 2010;1:135-142.
Overbey DM, Jones EL, Robinson TN. How hemostatic
agents interact with the coagulation cascade. AORN J.
2014;100(2):148-159.
Di Cera E. Thrombin. Mol Aspects Med. 2008;29(4):
203-254.
Spotnitz W, Burks S. Hemostats, sealants, and adhesives
II: update as well as how and when to use the components
of the surgical toolbox. Clin Appl Thromb Hemost. 2010;
16(5):497-514.
Garcia-Roig M, Gorin MA, Castellan M, Ciancio G.
OMNEX Surgical Sealant in the extracorporeal repair
of renal artery aneurysms. Ann Vasc Surg. 2011;25(8):
1141-1148.
Sundaram C, Keenan A. The evolution of hemostatic
agents in surgical practice. Indian J Urol. 2010;26(3):
374-378.
Australian Public Assessment Report for Fibrin Sealant.
Proprietary Product name: Artiss; Sponsor: Baxter Healthcare Pty Ltd. Commonwealth of Australia: Australian
Department of Health and Ageing, Therapeutic Goods
Administration; October 2010:1-53.
Margaret A. Camp, MSN, BSN, RN, is a

perioperative consultant in Aurora, CO. Having
received money for the development of education
programs and for travel, accommodations, and
meeting expenses from Ethicon, Ms Camp has
declared an affiliation that could be perceived
as posing a potential conflict of interest in the
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